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Mücke Y, Jablonka N, Rimann N, Grisch-Chan HM, Hoffmann B, Schillberg S, Thöny B, Rasche S. A phenylalanine-free recombinant nutritional protein for the dietary management of phenylketonuria. J Inherit Metab Dis 2024; 47:651-663. [PMID: 38390655 DOI: 10.1002/jimd.12719] [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: 09/21/2023] [Revised: 01/17/2024] [Accepted: 01/31/2024] [Indexed: 02/24/2024]
Abstract
Phenylketonuria (PKU) is a congenital metabolic disorder that causes the systemic elevation of phenylalanine (Phe), which is neurotoxic and teratogenic. PKU is currently incurable, and management involves lifelong adherence to an unpalatable protein-restricted diet based on Phe-free amino acid mixtures. Seeking a palatable dietary alternative, we identified a Bacillus subtilis protein (GSP16O) with a well-balanced but low-Phe amino acid profile. We optimized the sequence and expressed a modified Phe-free version (GSP105) in Pseudomonas fluorescens, achieving yields of 20 g/L. The purified GSP105 protein has a neutral taste and smell, is highly soluble, and remains stable up to 80°C. Homozygous enu2 mice, a model of human PKU, were fed with diets containing either GSP105 or normal protein. The GSP105 diet led to normalization of blood Phe levels and brain monoamine neurotransmitter metabolites, and prevented maternal PKU. The GSP105 diet thus provides an alternative and efficacious dietary management strategy for PKU.
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Affiliation(s)
- Yvonne Mücke
- metaX Institut für Diätetik GmbH, Friedberg, Germany
| | - Natalia Jablonka
- Fraunhofer-Institut für Molekularbiologie und Angewandte Oekologie IME, Aachen, Germany
| | - Nicole Rimann
- Division of Metabolism, Department of Pediatrics, University of Zürich, Zürich, Switzerland
| | - Hiu Man Grisch-Chan
- Division of Metabolism, Department of Pediatrics, University of Zürich, Zürich, Switzerland
| | | | - Stefan Schillberg
- Fraunhofer-Institut für Molekularbiologie und Angewandte Oekologie IME, Aachen, Germany
| | - Beat Thöny
- Division of Metabolism, Department of Pediatrics, University of Zürich, Zürich, Switzerland
| | - Stefan Rasche
- Fraunhofer-Institut für Molekularbiologie und Angewandte Oekologie IME, Aachen, Germany
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2
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Tosi M, Fiori L, Tagi VM, Gambino M, Montanari C, Bosetti A, Zuccotti G, Verduci E. Glycomacropeptide-Based Protein Substitutes for Children with Phenylketonuria in Italy: A Nutritional Comparison. Nutrients 2024; 16:956. [PMID: 38612990 PMCID: PMC11013192 DOI: 10.3390/nu16070956] [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: 02/25/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
Advancements in food science technology have allowed the development of new products for the therapeutic management of inherited metabolic diseases such as phenylketonuria (PKU). Glycomacropeptide (GMP), a peptide derived from casein, is naturally low in phenylalanine (Phe) and, thus, adequate for protein substitutes (PSs) for the management of PKU in children. This review aims primarily to analyse the differences in the nutritional composition of GMP-based protein substitutes in different formulations (ready to drink, powdered, and bars), and secondarily to assess the quality of these products, comparing their nutritional composition with that of standard amino acid (L-AA) mixtures. Thirty-five GMP-based PSs produced by six different companies were included in this review: twenty-one powdered PSs, eight ready to drink, and six bars. The analysis revealed great heterogeneity not only among the different formulations (powdered, ready to drink, and bars) but also within the same group, in terms of energy content and nutritional composition. GMP-based PSs were shown to have higher contents of sugars and saturated fatty acids compared to L-AA PSs, especially in ready-to-drink formulations and bars. The latter also provided the highest amounts of energy among the GMP-based products. This finding may be related to a higher risk of developing overweight and obesity. The greater palatability of these GMP-based PSs, combined with improved nutritional quality, could not only improve adherence to diet therapy but also reduce the incidence of obesity-related comorbidities in PKU.
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Affiliation(s)
- Martina Tosi
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (M.T.); (L.F.); (V.M.T.); (M.G.); (C.M.); (A.B.); (G.Z.)
- Department of Health Sciences, University of Milan, 20146 Milan, Italy
| | - Laura Fiori
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (M.T.); (L.F.); (V.M.T.); (M.G.); (C.M.); (A.B.); (G.Z.)
| | - Veronica Maria Tagi
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (M.T.); (L.F.); (V.M.T.); (M.G.); (C.M.); (A.B.); (G.Z.)
- Department of Biomedical and Clinical Science, University of Milan, 20157 Milan, Italy
| | - Mirko Gambino
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (M.T.); (L.F.); (V.M.T.); (M.G.); (C.M.); (A.B.); (G.Z.)
| | - Chiara Montanari
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (M.T.); (L.F.); (V.M.T.); (M.G.); (C.M.); (A.B.); (G.Z.)
- Department of Biomedical and Clinical Science, University of Milan, 20157 Milan, Italy
| | - Alessandra Bosetti
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (M.T.); (L.F.); (V.M.T.); (M.G.); (C.M.); (A.B.); (G.Z.)
| | - Gianvincenzo Zuccotti
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (M.T.); (L.F.); (V.M.T.); (M.G.); (C.M.); (A.B.); (G.Z.)
- Department of Biomedical and Clinical Science, University of Milan, 20157 Milan, Italy
| | - Elvira Verduci
- Department of Health Sciences, University of Milan, 20146 Milan, Italy
- Metabolic Diseases Unit, Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy
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Pinto A, Daly A, Rocha JC, Ashmore C, Evans S, Ilgaz F, Hickson M, MacDonald A. Natural Protein Intake in Children with Phenylketonuria: Prescription vs. Actual Intakes. Nutrients 2023; 15:4903. [PMID: 38068761 PMCID: PMC10708375 DOI: 10.3390/nu15234903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 11/16/2023] [Accepted: 11/19/2023] [Indexed: 12/18/2023] Open
Abstract
In phenylketonuria (PKU), an important component of the UK dietary management system is a 50 mg phenylalanine (Phe)/1 g protein exchange system used to allocate the Phe/natural protein intakes according to individual patient tolerance. Any foods containing protein ≤ 0.5 g/100 g or fruits/vegetables containing Phe ≤ 75 mg/100 g are allowed without measurement or limit. In children with PKU, we aimed to assess the difference between the prescribed natural protein intake and their actual consumed intake, and to calculate the natural protein/Phe intake from foods given without measurement or restriction. Over a 6-month duration, three one-day diet diaries were collected every month by caregivers of children with PKU at the beginning of a follow-up study. Dietary intakes of Phe, as well as natural and total protein intakes, were calculated using Nutritics® (v5.09). Weekly blood Phe spots were collected by caregivers. The target blood Phe level was ≤360 μmol/L for ages up to 12 years and ≤600 μmol/L for ages ≥12 years. Sixteen early treated children (69% females) with PKU were recruited. The median age was 11 years (range: 9-13), and most had classical PKU (n = 14/16). A median of 18 (range 12-18) one-day diaries and 22 blood spots were analysed for each subject over 6 months. The median prescribed natural protein was 6 g/day (range: 3-27), but when calculated, the actual median intake from all foods consumed was 10 g/day (range: 4-37). The median prescribed Phe was 300 mg/day (range: 150-1350), but the actual median intake was 500 mg/day (range: 200-1850). The median difference between the prescribed and actual natural protein daily intakes was +4 g/day (range: -2.5 to +11.5), with a median percentage increase of 40% for natural protein/Phe intake (p < 0.001). The median blood Phe level was 250 μmol/L (range 20-750), with 91% of blood Phe levels within the target range. Only one patient (11 years) had less than 75% of their blood Phe levels within the target range. The UK Phe exchange system provides flexibility in the dietary management of PKU. With this method, the actual natural protein intake was 167% higher than the prescribed amount. Although this led to a variable daily protein intake, the majority of children (n = 15/16) experienced no deterioration in their metabolic control.
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Affiliation(s)
- Alex Pinto
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (A.D.); (C.A.); (S.E.); (F.I.); (A.M.)
- Plymouth Institute of Health and Care Research, Faculty of Health, University of Plymouth, Plymouth PL6 8BH, UK;
| | - Anne Daly
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (A.D.); (C.A.); (S.E.); (F.I.); (A.M.)
| | - Júlio César Rocha
- Nutrition and Metabolism, NOVA Medical School (NMS), Faculdade de Ciências Médicas (FCM), Universidade Nova de Lisboa, 1169-056 Lisboa, Portugal;
- CINTESIS@RISE, Nutrition and Metabolism, NOVA Medical School (NMS), Faculdade de Ciências Médicas, (FCM), Universidade NOVA de Lisboa, 1169-056 Lisboa, Portugal
- Reference Centre of Inherited Metabolic Diseases, Centro Hospitalar Universitario de Lisboa Central, 1169-045 Lisboa, Portugal
| | - Catherine Ashmore
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (A.D.); (C.A.); (S.E.); (F.I.); (A.M.)
| | - Sharon Evans
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (A.D.); (C.A.); (S.E.); (F.I.); (A.M.)
| | - Fatma Ilgaz
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (A.D.); (C.A.); (S.E.); (F.I.); (A.M.)
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Hacettepe University, 06100 Ankara, Turkey
| | - Mary Hickson
- Plymouth Institute of Health and Care Research, Faculty of Health, University of Plymouth, Plymouth PL6 8BH, UK;
| | - Anita MacDonald
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (A.D.); (C.A.); (S.E.); (F.I.); (A.M.)
- Plymouth Institute of Health and Care Research, Faculty of Health, University of Plymouth, Plymouth PL6 8BH, UK;
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Adams AD, Fiesco-Roa MÓ, Wong L, Jenkins GP, Malinowski J, Demarest OM, Rothberg PG, Hobert JA. Phenylalanine hydroxylase deficiency treatment and management: A systematic evidence review of the American College of Medical Genetics and Genomics (ACMG). Genet Med 2023; 25:100358. [PMID: 37470789 DOI: 10.1016/j.gim.2022.12.005] [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: 12/05/2022] [Revised: 12/08/2022] [Accepted: 12/08/2022] [Indexed: 07/21/2023] Open
Abstract
PURPOSE Elevated serum phenylalanine (Phe) levels due to biallelic pathogenic variants in phenylalanine hydroxylase (PAH) may cause neurodevelopmental disorders or birth defects from maternal phenylketonuria. New Phe reduction treatments have been approved in the last decade, but uncertainty on the optimal lifespan goal Phe levels for patients with PAH deficiency remains. METHODS We searched Medline and Embase for evidence of treatment concerning PAH deficiency up to September 28, 2021. Risk of bias was evaluated based on study design. Random-effects meta-analyses were performed to compare IQ, gestational outcomes, and offspring outcomes based on Phe ≤ 360 μmol/L vs > 360 μmol/L and reported as odds ratio and 95% CI. Remaining results were narratively synthesized. RESULTS A total of 350 studies were included. Risk of bias was moderate. Lower Phe was consistently associated with better outcomes. Achieving Phe ≤ 360 μmol/L before conception substantially lowered the risk of negative effect to offspring in pregnant individuals (odds ratio = 0.07, 95% CI = 0.04-0.14; P < .0001). Adverse events due to pharmacologic treatment were common, but medication reduced Phe levels, enabling dietary liberalization. CONCLUSIONS Reduction of Phe levels to ≤360 μmol/L through diet or medication represents effective interventions to treat PAH deficiency.
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Affiliation(s)
- April D Adams
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX; Division of Maternal-Fetal Medicine, Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | - Moisés Ó Fiesco-Roa
- Programa de Maestría y Doctorado en Ciencias Médicas, Universidad Nacional Autónoma de México (UNAM), Mexico City, Mexico; Laboratorio de Citogenética, Instituto Nacional de Pediatría, Mexico City, Mexico
| | | | | | | | | | - Paul G Rothberg
- Department of Pathology & Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
| | - Judith A Hobert
- University of Utah School of Medicine, Salt Lake City, UT; ARUP Laboratories, Salt Lake City, UT
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5
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Delsoglio M, Capener R, MacDonald A, Daly A, Ashmore C, Ellerton C, Donald S, Gaff L, VanDorp L, Skeath R, Newby C, Dunning G, Dale C, Hunjan I, White L, Allen H, Hubbard GP, Stratton RJ. Evaluation of a New Glycomacropeptide-Based Protein Substitute in Powdered and Liquid Format in Patients with PKU. Nutrients 2023; 15:3580. [PMID: 37630769 PMCID: PMC10459497 DOI: 10.3390/nu15163580] [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: 06/23/2023] [Revised: 08/04/2023] [Accepted: 08/11/2023] [Indexed: 08/27/2023] Open
Abstract
(1) Background: Good adherence to a Phe-restricted diet supplemented with an adequate amount of a protein substitute (PS) is important for good clinical outcomes in PKU. Glycomacropeptide (cGMP)-PSs are innovative, palatable alternatives to amino acid-based PSs (AA-PS). This study aimed to evaluate a new cGMP-PS in liquid and powder formats in PKU. (2) Methods: Children and adults with PKU recruited from eight centres were prescribed at least one serving/day of cGMP-PS for 7-28 days. Adherence, acceptability, and gastrointestinal tolerance were recorded at baseline and the end of the intervention. The blood Phe levels reported as part of routine care during the intervention were recorded. (3) Results: In total, 23 patients (powder group, n = 13; liquid group, n = 10) completed the study. The majority assessed the products to be palatable (77% of powder group; 100% of liquid group) and well tolerated; the adherence to the product prescription was good. A total of 14 patients provided blood Phe results during the intervention, which were within the target therapeutic range for most patients (n = 11) at baseline and during the intervention. (4) Conclusions: These new cGMP-PSs were well accepted and tolerated, and their use did not adversely affect blood Phe control.
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Affiliation(s)
- Marta Delsoglio
- Research and Innovation, Nutricia Ltd., White Horse Business Park, Trowbridge BA14 0XQ, UK
| | - Rebecca Capener
- Research and Innovation, Nutricia Ltd., White Horse Business Park, Trowbridge BA14 0XQ, UK
| | - Anita MacDonald
- Dietetic Department, Birmingham Children’s Hospital, Birmingham B4 6NH, UK
| | - Anne Daly
- Dietetic Department, Birmingham Children’s Hospital, Birmingham B4 6NH, UK
| | - Catherine Ashmore
- Dietetic Department, Birmingham Children’s Hospital, Birmingham B4 6NH, UK
| | - Charlotte Ellerton
- University College London Hospitals NHS Foundation Trust, London WC1N 3BG, UK
| | - Sarah Donald
- Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Lisa Gaff
- Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Louise VanDorp
- Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - Rachel Skeath
- Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - Camille Newby
- Bristol University Hospitals NHS Foundation Trust, Bristol BS1 3NU, UK
| | - Georgina Dunning
- Bristol University Hospitals NHS Foundation Trust, Bristol BS1 3NU, UK
| | - Clare Dale
- Queen Elizabeth Hospital, Birmingham B15 2TH, UK
| | - Inderdip Hunjan
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford BD5 0NA, UK
| | - Lucy White
- Sheffield Children’s NHS Foundation Trust, Sheffield S10 2TH, UK
| | - Heather Allen
- Sheffield Children’s NHS Foundation Trust, Sheffield S10 2TH, UK
| | - Gary P. Hubbard
- Research and Innovation, Nutricia Ltd., White Horse Business Park, Trowbridge BA14 0XQ, UK
| | - Rebecca J. Stratton
- Research and Innovation, Nutricia Ltd., White Horse Business Park, Trowbridge BA14 0XQ, UK
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
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Pinto A, Ilgaz F, Evans S, van Dam E, Rocha JC, Karabulut E, Hickson M, Daly A, MacDonald A. Phenylalanine Tolerance over Time in Phenylketonuria: A Systematic Review and Meta-Analysis. Nutrients 2023; 15:3506. [PMID: 37630696 PMCID: PMC10458574 DOI: 10.3390/nu15163506] [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: 07/06/2023] [Revised: 07/29/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
In phenylketonuria (PKU), natural protein tolerance is defined as the maximum natural protein intake maintaining a blood phenylalanine (Phe) concentration within a target therapeutic range. Tolerance is affected by several factors, and it may differ throughout a person's lifespan. Data on lifelong Phe/natural protein tolerance are limited and mostly reported in studies with low subject numbers. This systematic review aimed to investigate how Phe/natural protein tolerance changes from birth to adulthood in well-controlled patients with PKU on a Phe-restricted diet. Five electronic databases were searched for articles published until July 2020. From a total of 1334 results, 37 articles met the eligibility criteria (n = 2464 patients), and 18 were included in the meta-analysis. The mean Phe (mg/day) and natural protein (g/day) intake gradually increased from birth until 6 y (at the age of 6 months, the mean Phe intake was 267 mg/day, and natural protein intake was 5.4 g/day; at the age of 5 y, the mean Phe intake was 377 mg/day, and the natural protein intake was 8.9 g/day). However, an increase in Phe/natural protein tolerance was more apparent at the beginning of late childhood and was >1.5-fold that of the Phe tolerance in early childhood. During the pubertal growth spurt, the mean natural protein/Phe tolerance was approximately three times higher than in the first year of life, reaching a mean Phe intake of 709 mg/day and a mean natural protein intake of 18 g/day. Post adolescence, a pooled analysis could only be performed for natural protein intake. The mean natural protein tolerance reached its highest (32.4 g/day) point at the age of 17 y and remained consistent (31.6 g/day) in adulthood, but limited data were available. The results of the meta-analysis showed that Phe/natural protein tolerance (expressed as mg or g per day) increases with age, particularly at the beginning of puberty, and reaches its highest level at the end of adolescence. This needs to be interpreted with caution as limited data were available in adult patients. There was also a high degree of heterogeneity between studies due to differences in sample size, the severity of PKU, and target therapeutic levels for blood Phe control.
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Affiliation(s)
- Alex Pinto
- Department of Dietetics, Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (S.E.); (A.D.); (A.M.)
- School of Health Professions, Faculty of Health, University of Plymouth, Plymouth PL4 6AB, UK;
| | - Fatma Ilgaz
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Hacettepe University, 06100 Ankara, Turkey;
| | - Sharon Evans
- Department of Dietetics, Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (S.E.); (A.D.); (A.M.)
| | - Esther van Dam
- Beatrix Children’s Hospital, University of Groningen, University Medical Center, 9700 RB Groningen, The Netherlands;
| | - Júlio César Rocha
- Nutrition and Metabolism, NOVA Medical School, Faculdade de Ciencias Medicas, Universidade Nova de Lisboa, 1169-056 Lisboa, Portugal;
- CINTESIS@RISE, NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM, Universidade Nova de Lisboa, 1169-056 Lisboa, Portugal
- Reference Centre of Inherited Metabolic Diseases, Centro Hospitalar Universitario de Lisboa Central, 1169-045 Lisboa, Portugal
| | - Erdem Karabulut
- Department of Biostatistics, Faculty of Medicine, Hacettepe University, 06100 Ankara, Turkey;
| | - Mary Hickson
- School of Health Professions, Faculty of Health, University of Plymouth, Plymouth PL4 6AB, UK;
| | - Anne Daly
- Department of Dietetics, Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (S.E.); (A.D.); (A.M.)
| | - Anita MacDonald
- Department of Dietetics, Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (S.E.); (A.D.); (A.M.)
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7
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Yilmaz O, Pinto A, Daly A, Ashmore C, Evans S, Yabanci Ayhan N, MacDonald A. Transitioning of protein substitutes in patients with phenylketonuria: evaluation of current practice. Orphanet J Rare Dis 2022; 17:395. [PMID: 36303225 PMCID: PMC9615388 DOI: 10.1186/s13023-022-02555-8] [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: 07/29/2022] [Accepted: 10/11/2022] [Indexed: 11/27/2022] Open
Abstract
Background In children with phenylketonuria (PKU), transitioning protein substitutes at the appropriate developmental age is essential to help with their long-term acceptance and ease of administration. We assessed the parental experiences in transitioning from a second stage to third stage liquid or powdered protein substitute in patients with PKU. Results Sixteen interviews (23 open-ended questions) were carried out with parents/caregivers of children with PKU (8 females, 50%) with a median age of 8 years (range 5–11 years), continuously treated with diet, and on a third stage protein substitute. Parents/caregivers identified common facilitators and barriers during the third stage protein substitute transition process. The main facilitators were: child and parent motivation, parent knowledge of the transition process, a role model with PKU, low volume and easy preparation of the third stage protein substitute (liquid/powder), anticipation of increasing child independence, lower parent workload, attractive packaging, better taste and smell, school and teacher support, dietetic plans and guidance, PKU social events, child educational materials and written resources. The main barriers were child aversion to new protein substitutes, poor child behaviour, child aged > 5 years, parental fear of change, the necessity for parental time and persistence, loss of parental control, high product volume, different taste, smell, and texture of new protein substitutes, and peer bullying. Conclusion A stepwise, supportive approach is necessary when transitioning from second to third stage protein substitutes in PKU. Future studies are needed to develop guidance to assist parents/caregivers, health professionals, and teachers during the transition process.
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Affiliation(s)
- Ozlem Yilmaz
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, B4 6NH, UK. .,Department of Nutrition and Dietetics, Faculty of Health Sciences, Ankara Yildirim Beyazit University, Ankara, 06760, Turkey. .,Department of Nutrition and Dietetics, Faculty of Health Sciences, Ankara University, Ankara, 06290, Turkey.
| | - Alex Pinto
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, B4 6NH, UK
| | - Anne Daly
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, B4 6NH, UK
| | - Catherine Ashmore
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, B4 6NH, UK
| | - Sharon Evans
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, B4 6NH, UK
| | - Nurcan Yabanci Ayhan
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Ankara University, Ankara, 06290, Turkey
| | - Anita MacDonald
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, B4 6NH, UK.
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8
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Glycomacropeptide in PKU-Does It Live Up to Its Potential? Nutrients 2022; 14:nu14040807. [PMID: 35215457 PMCID: PMC8875363 DOI: 10.3390/nu14040807] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/30/2022] [Accepted: 02/07/2022] [Indexed: 02/01/2023] Open
Abstract
The use of casein glycomacropeptide (CGMP) as a protein substitute in phenylketonuria (PKU) has grown in popularity. CGMP is derived from κ casein and is a sialic-rich glycophosphopeptide, formed by the action of chymosin during the production of cheese. It comprises 20–25% of total protein in whey products and has key biomodulatory properties. In PKU, the amino acid sequence of CGMP has been adapted by adding the amino acids histidine, leucine, methionine, tyrosine and tryptophan naturally low in CGMP. The use of CGMP compared to mono amino acids (L-AAs) as a protein substitute in the treatment of PKU promises several potential clinical benefits, although any advantage is supported only by evidence from non-PKU conditions or PKU animal models. This review examines if there is sufficient evidence to support the bioactive properties of CGMP leading to physiological benefits when compared to L-AAs in PKU, with a focus on blood phenylalanine control and stability, body composition, growth, bone density, breath odour and palatability.
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9
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Lim JY, Amit N, Ali NM, Leong HY, Mohamad M, Rajikan R. Effect of nutritional intervention on nutritional status among children with disorders of amino acid and nitrogen metabolism (AANMDs): A scoping review. Intractable Rare Dis Res 2021; 10:246-256. [PMID: 34877236 PMCID: PMC8630465 DOI: 10.5582/irdr.2021.01124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/29/2021] [Accepted: 11/02/2021] [Indexed: 12/15/2022] Open
Abstract
Disorders of amino acid and nitrogen metabolism (AANMDs) occur due to an enzyme deficiency in a normal biochemical pathway. Nutritional intervention is recognized as the mainstay of treatment for children diagnosed with AANMD. Hence, this scoping review aimed to identify the nutritional interventions available in managing AANMD disorders and their effects on nutritional status. A systematic search using PRISMA Extension for Scoping Reviews (PRISMA-ScR) method was conducted across 4 databases: PubMed, ScienceDirect (Elsevier), EBSCOhost and Cochrane Central Register of Controlled Trials (CENTRAL). Inclusion criteria for the study to be selected are: subjects aged less than 18-year-old, article published in English, utilized an experimental design and published within the past 20 years. A total of 22 articles were included in this review. The majority of the subjects are boys (55.6%) and employed a randomized controlled trial (RCT) study design (45.4%). Nutritional interventions were categorized into 4 categories which are: "protein substitute" (n = 5), "protein substitute with modified composition" (n = 6), "nutrient supplementation (n=8)", and "distribution and dosage of protein substitute (n = 3)". The most frequently assessed outcomes were biochemical parameters that gauge the effectiveness of metabolic control (68.2%). Overall, "protein substitute enriched with inhibitive amino acids", "long-chain polyunsaturated fatty acids supplementation", and "evenly distributed protein substitute" demonstrated beneficial effects towards the nutritional status, especially in terms of biochemical parameters. In summary, nutritional intervention plays a significant role in improving the nutritional status of AANMD patients. Further investigations of nutritional intervention among AANMD children using a meta-analysis approach are necessary for better comprehension of their impact in management of AANMD disorders.
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Affiliation(s)
- Jing Ying Lim
- Dietetics Program & Centre of Healthy Aging and Wellness (H-Care), Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Noh Amit
- Clinical Psychology and Behavioural Health Program & Center for Community Health Studies (ReaCH), Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Nazlena Mohamad Ali
- Institute of IR4.0 (IIR4.0), Universiti Kebangsaan Malaysia, Bangi, Selangor, Malaysia
| | - Huey Yin Leong
- Genetics Department, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Maslina Mohamad
- Dietetics & Food Service Department, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Roslee Rajikan
- Dietetics Program & Centre of Healthy Aging and Wellness (H-Care), Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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10
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Casein Glycomacropeptide: An Alternative Protein Substitute in Tyrosinemia Type I. Nutrients 2021; 13:nu13093224. [PMID: 34579102 PMCID: PMC8467066 DOI: 10.3390/nu13093224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/08/2021] [Accepted: 09/14/2021] [Indexed: 12/25/2022] Open
Abstract
Tyrosinemia type I (HTI) is treated with nitisinone, a tyrosine (Tyr) and phenylalanine (Phe)-restricted diet, and supplemented with a Tyr/Phe-free protein substitute (PS). Casein glycomacropeptide (CGMP), a bioactive peptide, is an alternative protein source to traditional amino acids (L-AA). CGMP contains residual Tyr and Phe and requires supplementation with tryptophan, histidine, methionine, leucine, cysteine and arginine. Aims: a 2-part study assessed: (1) the tolerance and acceptability of a low Tyr/Phe CGMP-based PS over 28 days, and (2) its long-term impact on metabolic control and growth over 12 months. Methods: 11 children with HTI were recruited and given a low Tyr/Phe CGMP to supply all or part of their PS intake. At enrolment, weeks 1 and 4, caregivers completed a questionnaire on gastrointestinal symptoms, acceptability and ease of PS use. In study part 1, blood Tyr and Phe were assessed weekly; in part 2, weekly to fortnightly. In parts 1 and 2, weight and height were assessed at the study start and end. Results: Nine of eleven children (82%), median age 15 years (range 8.6–17.7), took low Tyr/Phe CGMP PS over 28 days; it was continued for 12 months in n = 5 children. It was well accepted by 67% (n = 6/9), tolerated by 100% (n = 9/9) and improved gastrointestinal symptoms in 2 children. The median daily dose of protein equivalent from protein substitute was 60 g/day (range 45–60 g) with a median of 20 g/day (range 15 to 30 g) from natural protein. In part 2 (n = 5), a trend for improved blood Tyr was observed: 12 months pre-study, median Tyr was 490 μmol/L (range 200–600) and Phe 50 μmol/L (range 30–100); in the 12 months taking low Tyr/Phe CGMP PS, median Tyr was 430 μmol/L (range 270–940) and Phe 40 μmol/L (range 20–70). Normal height, weight and BMI z scores were maintained over 12 months. Conclusions: In HTI children, CGMP was well tolerated, with no deterioration in metabolic control or growth when studied over 12 months. The efficacy of CGMP in HTI needs further investigation to evaluate the longer-term impact on blood Phe concentrations and its potential influence on gut microflora
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11
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Daly A, Högler W, Crabtree N, Shaw N, Evans S, Pinto A, Jackson R, Ashmore C, Rocha JC, Strauss BJ, Wilcox G, Fraser WD, Tang JCY, MacDonald A. A Three-Year Longitudinal Study Comparing Bone Mass, Density, and Geometry Measured by DXA, pQCT, and Bone Turnover Markers in Children with PKU Taking L-Amino Acid or Glycomacropeptide Protein Substitutes. Nutrients 2021; 13:nu13062075. [PMID: 34204378 PMCID: PMC8233747 DOI: 10.3390/nu13062075] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 06/09/2021] [Indexed: 12/20/2022] Open
Abstract
In patients with phenylketonuria (PKU), treated by diet therapy only, evidence suggests that areal bone mineral density (BMDa) is within the normal clinical reference range but is below the population norm. Aims: To study longitudinal bone density, mass, and geometry over 36 months in children with PKU taking either amino acid (L-AA) or casein glycomacropeptide substitutes (CGMP-AA) as their main protein source. Methodology: A total of 48 subjects completed the study, 19 subjects in the L-AA group (median age 11.1, range 5–16 years) and 29 subjects in the CGMP-AA group (median age 8.3, range 5–16 years). The CGMP-AA was further divided into two groups, CGMP100 (median age 9.2, range 5–16 years) (n = 13), children taking CGMP-AA only and CGMP50 (median age 7.3, range 5–15 years) (n = 16), children taking a combination of CGMP-AA and L-AA. Dual X-ray absorptiometry (DXA) was measured at enrolment and 36 months, peripheral quantitative computer tomography (pQCT) at 36 months only, and serum blood and urine bone turnover markers (BTM) and blood bone biochemistry at enrolment, 6, 12, and 36 months. Results: No statistically significant differences were found between the three groups for DXA outcome parameters, i.e., BMDa (L2–L4 BMDa g/cm2), bone mineral apparent density (L2–L4 BMAD g/cm3) and total body less head BMDa (TBLH g/cm2). All blood biochemistry markers were within the reference ranges, and BTM showed active bone turnover with a trend for BTM to decrease with increasing age. Conclusions: Bone density was clinically normal, although the median z scores were below the population mean. BTM showed active bone turnover and blood biochemistry was within the reference ranges. There appeared to be no advantage to bone density, mass, or geometry from taking a macropeptide-based protein substitute as compared with L-AAs.
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Affiliation(s)
- Anne Daly
- Birmingham Women’s and Children’s Hospital, NHS Foundation Trust, Birmingham B4 6NH, UK; (N.C.); (N.S.); (S.E.); (A.P.); (C.A.); (A.M.)
- Correspondence:
| | - Wolfgang Högler
- Department of Paediatrics and Adolescent Medicine, Johannes Kepler University, Kepler University Hospital, Krankenhausstraße 26-30, 4020 Linz, Austria;
| | - Nicola Crabtree
- Birmingham Women’s and Children’s Hospital, NHS Foundation Trust, Birmingham B4 6NH, UK; (N.C.); (N.S.); (S.E.); (A.P.); (C.A.); (A.M.)
| | - Nick Shaw
- Birmingham Women’s and Children’s Hospital, NHS Foundation Trust, Birmingham B4 6NH, UK; (N.C.); (N.S.); (S.E.); (A.P.); (C.A.); (A.M.)
| | - Sharon Evans
- Birmingham Women’s and Children’s Hospital, NHS Foundation Trust, Birmingham B4 6NH, UK; (N.C.); (N.S.); (S.E.); (A.P.); (C.A.); (A.M.)
| | - Alex Pinto
- Birmingham Women’s and Children’s Hospital, NHS Foundation Trust, Birmingham B4 6NH, UK; (N.C.); (N.S.); (S.E.); (A.P.); (C.A.); (A.M.)
| | - Richard Jackson
- Liverpool Clinical Trials Centre, University of Liverpool, Brownlow Hill, Liverpool L69 3GL, UK;
| | - Catherine Ashmore
- Birmingham Women’s and Children’s Hospital, NHS Foundation Trust, Birmingham B4 6NH, UK; (N.C.); (N.S.); (S.E.); (A.P.); (C.A.); (A.M.)
| | - Júlio C. Rocha
- Nutrition and Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, 1169-056 Lisboa, Portugal;
- Centre for Health and Technology and Services Research (CINTESIS), 4200-450 Porto, Portugal
| | - Boyd J. Strauss
- School of Medical Sciences, Faculty of Biology, Medicine and Health Sciences, University of Manchester, Manchester M13 9PL, UK; (B.J.S.); (G.W.)
- School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne 3800, Australia
| | - Gisela Wilcox
- School of Medical Sciences, Faculty of Biology, Medicine and Health Sciences, University of Manchester, Manchester M13 9PL, UK; (B.J.S.); (G.W.)
- The Mark Holland Metabolic Unit, Salford Royal Foundation NHS Trust, Ladywell NW2, Salford, Manchester M6 8HD, UK
| | - William D. Fraser
- BioAnalytical Facility, BCRE Builiding University or East Anglia, Norwich NR4 7TJ, UK; (W.D.F.); (J.C.Y.T.)
| | - Jonathan C. Y. Tang
- BioAnalytical Facility, BCRE Builiding University or East Anglia, Norwich NR4 7TJ, UK; (W.D.F.); (J.C.Y.T.)
- Departments of Clinical Biochemistry and Endocrinology, Norfolk and Norwich University Hospitals Trust, Norwich NR4 7UY, UK
| | - Anita MacDonald
- Birmingham Women’s and Children’s Hospital, NHS Foundation Trust, Birmingham B4 6NH, UK; (N.C.); (N.S.); (S.E.); (A.P.); (C.A.); (A.M.)
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12
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Growth and Body Composition in PKU Children-A Three-Year Prospective Study Comparing the Effects of L-Amino Acid to Glycomacropeptide Protein Substitutes. Nutrients 2021; 13:nu13041323. [PMID: 33923714 PMCID: PMC8073059 DOI: 10.3390/nu13041323] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 04/10/2021] [Indexed: 01/15/2023] Open
Abstract
Protein quality and quantity are important factors in determining lean body (muscle) mass (LBM). In phenylketonuria (PKU), protein substitutes provide most of the nitrogen, either as amino acids (AA) or glycomacropeptide with supplementary amino acids (CGMP-AA). Body composition and growth are important indicators of long-term health. In a 3-year prospective study comparing the impact of AA and CGMP-AA on body composition and growth in PKU, 48 children were recruited. N = 19 (median age 11.1 years, range 5–15 years) took AA only, n = 16 (median age 7.3 years, range 5–15 years) took a combination of CGMP-AA and AA, (CGMP50) and 13 children (median age 9.2 years, range 5–16 years) took CGMP-AA only (CGMP100). A dual energy X-ray absorptiometry (DXA) scan at enrolment and 36 months measured LBM, % body fat (%BF) and fat mass (FM). Height was measured at enrolment, 12, 24 and 36 months. No correlation or statistically significant differences (after adjusting for age, gender, puberty and phenylalanine blood concentrations) were found between the three groups for LBM, %BF, FM and height. The change in height z scores, (AA 0, CGMP50 +0.4 and CGMP100 +0.7) showed a trend that children in the CGMP100 group were taller, had improved LBM with decreased FM and % BF but this was not statistically significant. There appeared to be no advantage of CGMP-AA compared to AA on body composition after 3-years of follow-up. Although statistically significant differences were not reached, a trend towards improved body composition was observed with CGMP-AA when it provided the entire protein substitute requirement.
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13
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Pena MJ, Pinto A, de Almeida MF, de Sousa Barbosa C, Ramos PC, Rocha S, Guimas A, Ribeiro R, Martins E, Bandeira A, Dias CC, MacDonald A, Borges N, Rocha JC. Continuous use of glycomacropeptide in the nutritional management of patients with phenylketonuria: a clinical perspective. Orphanet J Rare Dis 2021; 16:84. [PMID: 33581730 PMCID: PMC7881530 DOI: 10.1186/s13023-021-01721-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/02/2021] [Indexed: 11/22/2022] Open
Abstract
Background In phenylketonuria (PKU), modified casein glycomacropeptide supplements (CGMP-AA) are used as an alternative to the traditional phenylalanine (Phe)-free L-amino acid supplements (L-AA). However, studies focusing on the long-term nutritional status of CGMP-AA are lacking. This retrospective study evaluated the long-term impact of CGMP-AA over a mean of 29 months in 11 patients with a mean age at CGMP-AA onset of 28 years (range 15–43) [8 females; 2 hyperphenylalaninaemia (HPA), 3 mild PKU, 3 classical PKU and 3 late-diagnosed]. Outcome measures included metabolic control, anthropometry, body composition and biochemical parameters. Results CGMP-AA, providing 66% of protein equivalent intake from protein substitute, was associated with no significant change in blood Phe with CGMP-AA compared with baseline (562 ± 289 µmol/L vs 628 ± 317 µmol/L; p = 0.065). In contrast, blood tyrosine significantly increased on CGMP-AA (52.0 ± 19.2 μmol/L vs 61.4 ± 23.8 μmol/L; p = 0.027). Conclusions Biochemical nutritional markers remained unchanged which is an encouraging finding in adults with PKU, many of whom are unable to maintain full adherence with nutritionally fortified protein substitutes. Longitudinal, prospective studies with larger sample sizes are necessary to fully understand the metabolic impact of using CGMP-AA in PKU.
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Affiliation(s)
- Maria João Pena
- Departamento de Biomedicina, Unidade de Bioquímica, Faculdade de Medicina, Universidade do Porto, 4200-319, Porto, Portugal
| | - Alex Pinto
- Department of Dietetics, Birmingham Children's Hospital, Birmingham, B4 6NH, UK.,Faculty of Health and Human Sciences, University of Plymouth, Plymouth, PL6 8BH, UK
| | - Manuela Ferreira de Almeida
- Centro de Genética Médica, Centro Hospitalar Universitário Do Porto (CHUP), 4099-028, Porto, Portugal.,Centro de Referência na área das Doenças Hereditárias do Metabolismo, CHUP, 4099-001, Porto, Portugal.,UMIB/ICBAS/UP), Unit for Multidisplinary Research in Biomedicine, Abel Salazar Institute of Biomedical Sciences, University of Porto, 4050-313, Porto, Portugal
| | - Catarina de Sousa Barbosa
- Centro de Genética Médica, Centro Hospitalar Universitário Do Porto (CHUP), 4099-028, Porto, Portugal.,Centro de Referência na área das Doenças Hereditárias do Metabolismo, CHUP, 4099-001, Porto, Portugal
| | - Paula Cristina Ramos
- Centro de Genética Médica, Centro Hospitalar Universitário Do Porto (CHUP), 4099-028, Porto, Portugal.,Centro de Referência na área das Doenças Hereditárias do Metabolismo, CHUP, 4099-001, Porto, Portugal
| | - Sara Rocha
- Centro de Referência na área das Doenças Hereditárias do Metabolismo, CHUP, 4099-001, Porto, Portugal
| | - Arlindo Guimas
- Centro de Referência na área das Doenças Hereditárias do Metabolismo, CHUP, 4099-001, Porto, Portugal
| | - Rosa Ribeiro
- Centro de Referência na área das Doenças Hereditárias do Metabolismo, CHUP, 4099-001, Porto, Portugal.,UMIB/ICBAS/UP), Unit for Multidisplinary Research in Biomedicine, Abel Salazar Institute of Biomedical Sciences, University of Porto, 4050-313, Porto, Portugal
| | - Esmeralda Martins
- Centro de Referência na área das Doenças Hereditárias do Metabolismo, CHUP, 4099-001, Porto, Portugal.,UMIB/ICBAS/UP), Unit for Multidisplinary Research in Biomedicine, Abel Salazar Institute of Biomedical Sciences, University of Porto, 4050-313, Porto, Portugal
| | - Anabela Bandeira
- Centro de Referência na área das Doenças Hereditárias do Metabolismo, CHUP, 4099-001, Porto, Portugal
| | - Cláudia Camila Dias
- Center for Health Technology and Services Research (CINTESIS), 4200-450, Porto, Portugal.,Department of Community Medicine, Information and Health Sciences (MEDCIDS), Faculty of Medicine, University of Porto, 4200-450, Porto, Portugal
| | - Anita MacDonald
- Department of Dietetics, Birmingham Children's Hospital, Birmingham, B4 6NH, UK
| | - Nuno Borges
- Center for Health Technology and Services Research (CINTESIS), 4200-450, Porto, Portugal.,Faculdade de Ciências da Nutrição e Alimentação, Universidade do Porto, 4150-180, Porto, Portugal
| | - Júlio César Rocha
- Centro de Genética Médica, Centro Hospitalar Universitário Do Porto (CHUP), 4099-028, Porto, Portugal. .,Centro de Referência na área das Doenças Hereditárias do Metabolismo, CHUP, 4099-001, Porto, Portugal. .,Center for Health Technology and Services Research (CINTESIS), 4200-450, Porto, Portugal. .,Nutrition and Metabolism, Nova Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, 1169-056, Lisbon, Portugal.
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14
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Verduci E, Carbone MT, Borghi E, Ottaviano E, Burlina A, Biasucci G. Nutrition, Microbiota and Role of Gut-Brain Axis in Subjects with Phenylketonuria (PKU): A Review. Nutrients 2020; 12:E3319. [PMID: 33138040 PMCID: PMC7692600 DOI: 10.3390/nu12113319] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 10/27/2020] [Indexed: 12/12/2022] Open
Abstract
The composition and functioning of the gut microbiota, the complex population of microorganisms residing in the intestine, is strongly affected by endogenous and exogenous factors, among which diet is key. Important perturbations of the microbiota have been observed to contribute to disease risk, as in the case of neurological disorders, inflammatory bowel disease, obesity, diabetes, cardiovascular disease, among others. Although mechanisms are not fully clarified, nutrients interacting with the microbiota are thought to affect host metabolism, immune response or disrupt the protective functions of the intestinal barrier. Similarly, key intermediaries, whose presence may be strongly influenced by dietary habits, sustain the communication along the gut-brain-axis, influencing brain functions in the same way as the brain influences gut activity. Due to the role of diet in the modulation of the microbiota, its composition is of high interest in inherited errors of metabolism (IEMs) and may reveal an appealing therapeutic target. In IEMs, for example in phenylketonuria (PKU), since part of the therapeutic intervention is based on chronic or life-long tailored dietetic regimens, important variations of the microbial diversity or relative abundance have been observed. A holistic approach, including a healthy composition of the microbiota, is recommended to modulate host metabolism and affected neurological functions.
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Affiliation(s)
- Elvira Verduci
- Department of Paediatrics, Vittore Buzzi Children’s Hospital-University of Milan, Via Lodovico Castelvetro, 32, 20154 Milan, Italy
- Department of Health Science, University of Milan, via di Rudinì 8, 20142 Milan, Italy; (E.B.); (E.O.)
| | - Maria Teresa Carbone
- UOS Metabolic and Rare Diseases, AORN Santobono, Via Mario Fiore 6, 80122 Naples, Italy;
| | - Elisa Borghi
- Department of Health Science, University of Milan, via di Rudinì 8, 20142 Milan, Italy; (E.B.); (E.O.)
| | - Emerenziana Ottaviano
- Department of Health Science, University of Milan, via di Rudinì 8, 20142 Milan, Italy; (E.B.); (E.O.)
| | - Alberto Burlina
- Division of Inborn Metabolic Diseases, Department of Diagnostic Services, University Hospital of Padua, Via Orus 2B, 35129 Padua, Italy;
| | - Giacomo Biasucci
- Department of Paediatrics & Neonatology, Guglielmo da Saliceto Hospital, Via Taverna Giuseppe, 49, 29121 Piacenza, Italy;
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15
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The Impact of the Use of Glycomacropeptide on Satiety and Dietary Intake in Phenylketonuria. Nutrients 2020; 12:nu12092704. [PMID: 32899700 PMCID: PMC7576483 DOI: 10.3390/nu12092704] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 08/28/2020] [Accepted: 09/01/2020] [Indexed: 12/15/2022] Open
Abstract
Protein is the most satiating macronutrient, increasing secretion of gastrointestinal hormones and diet induced thermogenesis. In phenylketonuria (PKU), natural protein is restricted with approximately 80% of intake supplied by a synthetic protein source, which may alter satiety response. Casein glycomacropeptide (CGMP-AA), a carbohydrate containing peptide and alternative protein substitute to amino acids (AA), may enhance satiety mediated by its bioactive properties. Aim: In a three-year longitudinal; prospective study, the effect of AA and two different amounts of CGMP-AA (CGMP-AA only (CGMP100) and a combination of CGMP-AA and AA (CGMP50) on satiety, weight and body mass index (BMI) were compared. Methods: 48 children with PKU completed the study. Median ages of children were: CGMP100; (n = 13), 9.2 years; CGMP50; (n = 16), 7.3 years; and AA (n = 19), 11.1 years. Semi-quantitative dietary assessments and anthropometry (weight, height and BMI) were measured every three months. Results: The macronutrient contribution to total energy intake from protein, carbohydrate and fat was similar across the groups. Adjusting for age and gender, no differences in energy intake, weight, BMI, incidence of overweight or obesity was apparent between the groups. Conclusion: In this three-year longitudinal study, there was no indication to support a relationship between CGMP and satiety, as evidenced by decreased energy intake, thereby preventing overweight or obesity. Satiety is a complex multi-system process that is not fully understood.
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Daly A, Evans S, Pinto A, Jackson R, Ashmore C, Rocha JC, MacDonald A. Preliminary Investigation to Review If a Glycomacropeptide Compared to L-Amino Acid Protein Substitute Alters the Pre- and Postprandial Amino Acid Profile in Children with Phenylketonuria. Nutrients 2020; 12:E2443. [PMID: 32823853 PMCID: PMC7468934 DOI: 10.3390/nu12082443] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 08/11/2020] [Accepted: 08/11/2020] [Indexed: 12/24/2022] Open
Abstract
In Phenylketonuria (PKU), the peptide structure of the protein substitute (PS), casein glycomacropeptide (CGMP), is supplemented with amino acids (CGMP-AA). CGMP may slow the rate of amino acid (AA) absorption compared with traditional phenylalanine-free amino acids (Phe-free AA), which may improve nitrogen utilization, decrease urea production, and alter insulin response. AIM In children with PKU, to compare pre and postprandial AA concentrations when taking one of three PS's: Phe-free AA, CGMP-AA 1 or 2. METHODS 43 children (24 boys, 19 girls), median age 9 years (range 5-16 years) were studied; 11 took CGMP-AA1, 18 CGMP-AA2, and 14 Phe-free AA. Early morning fasting pre and 2 h postprandial blood samples were collected for quantitative AA on one occasion. A breakfast with allocated 20 g protein equivalent from PS was given post fasting blood sample. RESULTS There was a significant increase in postprandial AA for all individual AAs with all three PS. Postprandial AA histidine (p < 0.001), leucine (p < 0.001), and tyrosine (p < 0.001) were higher in CGMP-AA2 than CGMP-AA1, and leucine (p < 0.001), threonine (p < 0.001), and tyrosine (p = 0.003) higher in GCMP-AA2 than Phe-free AA. This was reflective of the AA composition of the three different PS's. CONCLUSIONS In PKU, the AA composition of CGMP-AA influences 2 h postprandial AA composition, suggesting that a PS derived from CGMP-AA may be absorbed similarly to Phe-free AA, but this requires further investigation.
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Affiliation(s)
- Anne Daly
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
| | - Sharon Evans
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
| | - Alex Pinto
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
| | - Richard Jackson
- Liverpool Clinical Trials Centre, University of Liverpool, Brownlow Hill, Liverpool L69 3GL, UK;
| | - Catherine Ashmore
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
| | - Júlio César Rocha
- Nutrition and Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, 1169-056 Lisboa, Portugal;
- Centre for Health Technology and Services Research (CINTESIS), 4200-450 Porto, Portugal
| | - Anita MacDonald
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
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17
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Manta-Vogli PD, Dotsikas Y, Loukas YL, Schulpis KH. The phenylketonuria patient: A recent dietetic therapeutic approach. Nutr Neurosci 2020; 23:628-639. [PMID: 30359206 DOI: 10.1080/1028415x.2018.1538196] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Phenylalanine hydroxylase (PAH) deficiency, commonly named phenylketonuria (PKU) is a disorder of phenylalanine (Phe) metabolism inherited with an autosomal recessive trait. It is characterized by high blood and cerebral Phe levels, resulting in intellectual disabilities, seizures, etc. Early diagnosis and treatment of the patients prevent major neuro-cognitive deficits. Treatment consists of a lifelong restriction of Phe intake, combined with the supplementation of special medical foods, such as Amino Acid medical food (AA-mf), enriched in tyrosine (Tyr) and other amino acids and nutrients to avoid nutritional deficits. Developmental and neurocognitive outcomes for patients, however, remain suboptimal, especially when adherence to the demanding diet is poor. Additions to treatment include new, more palatable foods, based on Glycomacropeptide that contains limited amounts of Phe, the administration of large neutral amino acids to prevent phenylalanine entry into the brain and tetrahydrobiopterin cofactor capable of increasing residual PAH activity. Moreover, further efforts are underway to develop an oral therapy containing phenylalanine ammonia-lyase. Nutritional support of PKU future mothers (maternal PKU) is also discussed. This review aims to summarize the current literature on new PKU treatment strategies.
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Affiliation(s)
- Penelope D Manta-Vogli
- Department of Clinical Nutrition & Dietetics Agia Sofia Children's Hospital, Athens, Greece
| | - Yannis Dotsikas
- Department of Pharmacy, Laboratory of Pharm. Analysis, National and Kapodestrian University of Athens, Panepistimiopolis Zographou, GR 157 71, Athens, Greece
| | - Yannis L Loukas
- Department of Pharmacy, Laboratory of Pharm. Analysis, National and Kapodestrian University of Athens, Panepistimiopolis Zographou, GR 157 71, Athens, Greece
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MacDonald A, van Wegberg AMJ, Ahring K, Beblo S, Bélanger-Quintana A, Burlina A, Campistol J, Coşkun T, Feillet F, Giżewska M, Huijbregts SC, Leuzzi V, Maillot F, Muntau AC, Rocha JC, Romani C, Trefz F, van Spronsen FJ. PKU dietary handbook to accompany PKU guidelines. Orphanet J Rare Dis 2020; 15:171. [PMID: 32605583 PMCID: PMC7329487 DOI: 10.1186/s13023-020-01391-y] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 05/04/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Phenylketonuria (PKU) is an autosomal recessive inborn error of phenylalanine metabolism caused by deficiency in the enzyme phenylalanine hydroxylase that converts phenylalanine into tyrosine. MAIN BODY In 2017 the first European PKU Guidelines were published. These guidelines contained evidence based and/or expert opinion recommendations regarding diagnosis, treatment and care for patients with PKU of all ages. This manuscript is a supplement containing the practical application of the dietary treatment. CONCLUSION This handbook can support dietitians, nutritionists and physicians in starting, adjusting and maintaining dietary treatment.
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Affiliation(s)
- A MacDonald
- Dietetic Department, Birmingham Children's Hospital, Birmingham, UK
| | - A M J van Wegberg
- Division of Metabolic Diseases, Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9700, RB, Groningen, The Netherlands
| | - K Ahring
- Department of PKU, Kennedy Centre, Glostrup, Denmark
| | - S Beblo
- Department of Women and Child Health, Center for Pediatric Research Leipzig, Hospital for Children and Adolescents, University Hospitals, Leipzig, Germany
| | - A Bélanger-Quintana
- Metabolic Diseases Unit, Department of Paediatrics, Hospital Ramon y Cajal Madrid, Madrid, Spain
| | - A Burlina
- Division of Inherited Metabolic Diseases, Department of Paediatrics, University Hospital of Padova, Padova, Italy
| | - J Campistol
- Neuropaediatrics Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - T Coşkun
- Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - F Feillet
- Department of Paediatrics, Hôpital d'Enfants Brabois, CHU Nancy, Vandoeuvre les Nancy, France
| | - M Giżewska
- Department of Paediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology of the Developmental Age, Pomeranian Medical University, Szczecin, Poland
| | - S C Huijbregts
- Department of Clinical Child and Adolescent Studies-Neurodevelopmental Disorders, Faculty of Social Sciences, Leiden University, Leiden, The Netherlands
| | - V Leuzzi
- Department of Paediatrics, Child Neurology and Psychiatry, Sapienza University of Rome, Via dei Sabelli 108, 00185, Rome, Italy
| | - F Maillot
- CHRU de Tours, Université François Rabelais, INSERM U1069, Tours, France
| | - A C Muntau
- University Children's Hospital, University Medical Centre Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - J C Rocha
- Nutrition & Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal. Centre for Health Technology and Services Research (CINTESIS), Porto, Portugal
| | - C Romani
- School of Life and Health Sciences, Aston University, Birmingham, UK
| | - F Trefz
- Department of Paediatrics, University of Heidelberg, Heidelberg, Germany
| | - F J van Spronsen
- Division of Metabolic Diseases, Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9700, RB, Groningen, The Netherlands.
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19
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van Vliet D, van der Goot E, van Ginkel WG, van Faassen MHJR, de Blaauw P, Kema IP, Martinez A, Heiner-Fokkema MR, van der Zee EA, van Spronsen FJ. The Benefit of Large Neutral Amino Acid Supplementation to a Liberalized Phenylalanine-Restricted Diet in Adult Phenylketonuria Patients: Evidence from Adult Pah-Enu2 Mice. Nutrients 2019; 11:E2252. [PMID: 31546852 PMCID: PMC6770592 DOI: 10.3390/nu11092252] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 09/13/2019] [Accepted: 09/17/2019] [Indexed: 11/16/2022] Open
Abstract
Many phenylketonuria (PKU) patients cannot adhere to the severe dietary restrictions as advised by the European PKU guidelines, which can be accompanied by aggravated neuropsychological impairments that, at least in part, have been attributed to brain monoaminergic neurotransmitter deficiencies. Supplementation of large neutral amino acids (LNAA) to an unrestricted diet has previously been shown to effectively improve brain monoamines in PKU mice of various ages. To determine the additive value of LNAA supplementation to a liberalized phenylalanine-restricted diet, brain and plasma monoamine and amino acid concentrations in 10 to 16-month-old adult C57Bl/6 PKU mice on a less severe phenylalanine-restricted diet with LNAA supplementation were compared to those on a non-supplemented severe or less severe phenylalanine-restricted diet. LNAA supplementation to a less severe phenylalanine-restricted diet was found to improve both brain monoamine and phenylalanine concentrations. Compared to a severe phenylalanine-restricted diet, it was equally effective to restore brain norepinephrine and serotonin even though being less effective to reduce brain phenylalanine concentrations. These results in adult PKU mice support the idea that LNAA supplementation may enhance the effect of a less severe phenylalanine-restricted diet and suggest that cerebral outcome of PKU patients treated with a less severe phenylalanine-restricted diet may be helped by additional LNAA treatment.
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Affiliation(s)
- Danique van Vliet
- Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands.
| | - Els van der Goot
- Department of Molecular Neurobiology, Groningen Institute for Evolutionary Life Sciences (GELIFES), University of Groningen, 9700 RB Groningen, The Netherlands.
| | - Wiggert G van Ginkel
- Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands.
| | - Martijn H J R van Faassen
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands.
| | - Pim de Blaauw
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands.
| | - Ido P Kema
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands.
| | - Aurora Martinez
- Department of Biomedicine and K.G. Jebsen Centre for Neuropsychiatric Disorders, University of Bergen, 5009 Bergen, Norway.
| | - M Rebecca Heiner-Fokkema
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands.
| | - Eddy A van der Zee
- Department of Molecular Neurobiology, Groningen Institute for Evolutionary Life Sciences (GELIFES), University of Groningen, 9700 RB Groningen, The Netherlands.
| | - Francjan J van Spronsen
- Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands.
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20
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Krüger CCH, Azevedo TD, Piltz MT, Silva ÁT, Cândido LMB. Casein-derived peptides as an alternative ingredient for low-phenylalanine diets. NUTR HOSP 2019; 36:718-722. [PMID: 30958685 DOI: 10.20960/nh.2391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023] Open
Abstract
Introduction: casein-derived peptides can be liberated both in vivo via normal digestion of casein, as well as in vitro via enzymatic hydrolysis. These peptides were suggested to have biological activity. Objectives: the aim of this study was to describe the production and characterization of casein peptides and to explore the potential of these peptides as an option for low-phenylalanine diets. Methods: peptides were produced by tryptic hydrolysis of sodium caseinate and acid precipitation with HCl, followed by precipitation with ethanol or aggregation of CaCl2 or ZnSO4. Results: the amino acid analysis revealed a significant reduction in the amount of phenylalanine from the original protein. Conclusion: casein-derived peptides could be a future alternative of short chain peptides to low-phenylalanine formulations.
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Affiliation(s)
| | - Thaise D Azevedo
- Food and Nutrition Post Graduate Program. Federal University of Paraná
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21
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Daly A, Evans S, Chahal S, Santra S, Pinto A, Jackson R, Gingell C, Rocha J, Van Spronsen FJ, MacDonald A. Glycomacropeptide: long-term use and impact on blood phenylalanine, growth and nutritional status in children with PKU. Orphanet J Rare Dis 2019; 14:44. [PMID: 30770754 PMCID: PMC6377744 DOI: 10.1186/s13023-019-1011-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 01/28/2019] [Indexed: 11/24/2022] Open
Abstract
Abstract In phenylketonuria, casein glycomacropeptide (CGMP) requires modification with the addition of some essential and semi essential amino acids to ensure suitability as a protein substitute. The optimal amount and ratio of additional amino acids is undefined. Aim A longitudinal, parallel, controlled study over 12 months evaluating a CGMP (CGMP-AA2) formulation compared with phenylalanine-free L-amino acid supplements (L-AA) on blood Phe, Tyr, Phe:Tyr ratio, biochemical nutritional status and growth in children with PKU. The CGMP-AA2 contained 36 mg Phe per 20 g protein equivalent. Methods Children with PKU, with a median age of 9.2 y (5-16y) were divided into 2 groups: 29 were given CGMP-AA2, 19 remained on Phe-free L-AA. The CGMP-AA2 formula gradually replaced L-AA, providing blood Phe concentrations were maintained within target range. Median blood Phe, Tyr, Phe:Tyr ratio and anthropometry, were compared within and between the two groups at baseline, 26 and 52 weeks. Nutritional biochemistry was studied at baseline and 26 weeks only. Results At the end of 52 weeks only 48% of subjects were able to completely use CGMP-AA2 as their single source of protein substitute. At 52 weeks CGMP-AA2 provided a median of 75% (30–100) of the total protein substitute with the remainder being given as L-AA. Within the CGMP-AA2 group, blood Phe increased significantly between baseline and 52 weeks: [baseline to 26 weeks; baseline Phe 270 μmol/L (170–430); 26 weeks, Phe 300 μmol/L (125–485) p = 0.06; baseline to 52 weeks: baseline, Phe 270 μmol/L (170–430), 52 weeks Phe 300 μmol/L (200–490), p < 0.001)]. However, there were no differences between the CGMP-AA2 and L-AA group for Phe, Tyr, Phe:Tyr ratio or anthropometry at any of the three measured time points. Within the CGMP-AA2 group only weight (p = 0.0001) and BMI z scores (p = 0.0001) increased significantly between baseline to 52 weeks. Whole blood and plasma selenium were significantly higher (whole blood selenium [p = 0.0002]; plasma selenium [p = 0.0007]) at 26 weeks in the CGMP-AA2 group compared L-AA. No differences were observed within the L-AA group for any of the nutritional markers. Conclusions CGMP-AA increases blood Phe concentrations and so it can only be used partly to contribute to protein substitute in some children with PKU. CGMP-AA should be carefully introduced in children with PKU and close monitoring of blood Phe control is essential. Electronic supplementary material The online version of this article (10.1186/s13023-019-1011-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- A Daly
- Dietetic Department, Birmingham Childrens Hospital, Steelhouse Lane, Birmingham, B4 6 NH, UK.
| | - S Evans
- Dietetic Department, Birmingham Childrens Hospital, Steelhouse Lane, Birmingham, B4 6 NH, UK
| | - S Chahal
- Dietetic Department, Birmingham Childrens Hospital, Steelhouse Lane, Birmingham, B4 6 NH, UK
| | - S Santra
- Dietetic Department, Birmingham Childrens Hospital, Steelhouse Lane, Birmingham, B4 6 NH, UK
| | - A Pinto
- University of Liverpool, Brownlow Street, Liverpool, L69 3GL, UK
| | - R Jackson
- Nottingham Queen's Medical Centre, University Hospital, Derby Road, Nottingham, NG7 2UH, UK
| | - C Gingell
- Centro de Genética Médica JM, CHP EPE, Porto, Portugal.,Centro de Referência na área das Doenças Hereditárias do Metabolismo, Centro Hospitalar do Porto - CHP EPE, Porto, Portugal.,Faculdade de Ciências da Saúde, UFP, Porto, Portugal.,Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
| | - J Rocha
- Beatrix Children's Hospital, University Medical Centre of Groningen, University of Groningen, Groningen, The Netherlands
| | - F J Van Spronsen
- Dietetic Department, Birmingham Childrens Hospital, Steelhouse Lane, Birmingham, B4 6 NH, UK
| | - A MacDonald
- Dietetic Department, Birmingham Childrens Hospital, Steelhouse Lane, Birmingham, B4 6 NH, UK
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22
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Evans S, Ford S, Adam S, Adams S, Ash J, Ashmore C, Caine G, Carruthers R, Cawtherley S, Chahal S, Clark A, Cochrane B, Daly A, Dines K, Dixon M, Dunlop C, Ellerton C, French M, Gaff L, Gingell C, Green D, Gribben J, Grimsley A, Hallam P, Hendroff U, Hill M, Hoban R, Howe S, Hunjan I, Kaalund K, Kelleher E, Khan F, Kitchen S, Lang K, Lowry S, Males J, Martin G, McStravick N, Micciche A, Newby C, Nicol C, Pereira R, Robertson L, Ross K, Simpson E, Singleton K, Skeath R, Stafford J, Terry A, Thom R, Tooke A, vanWyk K, White F, White L, MacDonald A. Development of national consensus statements on food labelling interpretation and protein allocation in a low phenylalanine diet for PKU. Orphanet J Rare Dis 2019; 14:2. [PMID: 30606267 PMCID: PMC6318866 DOI: 10.1186/s13023-018-0950-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 11/02/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the treatment of phenylketonuria (PKU), there was disparity between UK dietitians regarding interpretation of how different foods should be allocated in a low phenylalanine diet (allowed without measurement, not allowed, or allowed as part of phenylalanine exchanges). This led to variable advice being given to patients. METHODOLOGY In 2015, British Inherited Metabolic Disease Group (BIMDG) dietitians (n = 70) were sent a multiple-choice questionnaire on the interpretation of protein from food-labels and the allocation of different foods. Based on majority responses, 16 statements were developed. Over 18-months, using Delphi methodology, these statements were systematically reviewed and refined with a facilitator recording discussion until a clear majority was attained for each statement. In Phase 2 and 3 a further 7 statements were added. RESULTS The statements incorporated controversial dietary topics including: a practical 'scale' for guiding calculation of protein from food-labels; a general definition for exchange-free foods; and guidance for specific foods. Responses were divided into paediatric and adult groups. Initially, there was majority consensus (≥86%) by paediatric dietitians (n = 29) for 14 of 16 statements; a further 2 structured discussions were required for 2 statements, with a final majority consensus of 72% (n = 26/36) and 64% (n = 16/25). In adult practice, 75% of dietitians agreed with all initial statements for adult patients and 40% advocated separate maternal-PKU guidelines. In Phase 2, 5 of 6 statements were agreed by ≥76% of respondents with one statement requiring a further round of discussion resulting in 2 agreed statements with a consensus of ≥71% by dietitians in both paediatric and adult practice. In Phase 3 one statement was added to elaborate further on an initial statement, and this received 94% acceptance by respondents. Statements were endorsed by the UK National Society for PKU. CONCLUSIONS The BIMDG dietitians group have developed consensus dietetic statements that aim to harmonise dietary advice given to patients with PKU across the UK, but monitoring of statement adherence by health professionals and patients is required.
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Affiliation(s)
- British Inherited Metabolic Diseases Group (BIMDG) Dietitians Group
- Dietetic Department, Birmingham Women’s & Children’s NHS Foundation Trust, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham, B4 6NH UK
- The National Society for Phenylketonuria, London, UK
- Queen Elizabeth University Hospital, Glasgow, UK
- Royal Victoria Infirmary, Newcastle upon Tyne, UK
- University Hospital of Wales, Cardiff, UK
- Mid Yorkshire Hospitals NHS Trust, Yorkshire, UK
- University College London Hospitals NHS Foundation Trust, London, UK
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Children’s University Hospital Dublin, Dublin, Republic of Ireland
- Belfast Health & Social Care Trust, Belfast, UK
- Royal Hospital for Sick Children Edinburgh, Edinburgh, UK
- Leicester Royal Infirmary, Leicester, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
- Salford Royal NHS Foundation Trust, Salford, UK
- Evelina London Children’s Healthcare, London, UK
- Mater Misericordiae University Hospital Dublin, Dublin, Ireland
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
- Ninewells Hospital Dundee, Dundee, Scotland
- Sheffield Children’s NHS Foundation Trust, Sheffield, UK
- Aneurin Bevan University Health Board Wales, Newport, UK
- Bristol Royal Hospital for Children, Bristol, UK
- Norfolk and Norwich University Hospital, Norfolk, UK
- Royal Aberdeen Children’s Hospital, Aberdeen, UK
- Royal Manchester Children’s Hospital, Manchester, UK
- Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Sharon Evans
- Dietetic Department, Birmingham Women’s & Children’s NHS Foundation Trust, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham, B4 6NH UK
| | - Suzanne Ford
- The National Society for Phenylketonuria, London, UK
| | - Sarah Adam
- Queen Elizabeth University Hospital, Glasgow, UK
| | - Sandra Adams
- Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Jane Ash
- University Hospital of Wales, Cardiff, UK
| | - Catherine Ashmore
- Dietetic Department, Birmingham Women’s & Children’s NHS Foundation Trust, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham, B4 6NH UK
| | | | - Rachel Carruthers
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Sarah Cawtherley
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Satnam Chahal
- Dietetic Department, Birmingham Women’s & Children’s NHS Foundation Trust, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham, B4 6NH UK
| | - Anne Clark
- Children’s University Hospital Dublin, Dublin, Republic of Ireland
| | | | - Anne Daly
- Dietetic Department, Birmingham Women’s & Children’s NHS Foundation Trust, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham, B4 6NH UK
| | - Karen Dines
- Belfast Health & Social Care Trust, Belfast, UK
| | - Marjorie Dixon
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Carolyn Dunlop
- Royal Hospital for Sick Children Edinburgh, Edinburgh, UK
| | | | | | - Lisa Gaff
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Cerys Gingell
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Diane Green
- Salford Royal NHS Foundation Trust, Salford, UK
| | | | | | - Paula Hallam
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Una Hendroff
- Mater Misericordiae University Hospital Dublin, Dublin, Ireland
| | - Melanie Hill
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rachel Hoban
- Dietetic Department, Birmingham Women’s & Children’s NHS Foundation Trust, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham, B4 6NH UK
| | - Sarah Howe
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Inderdip Hunjan
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Kit Kaalund
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Eimear Kelleher
- Mater Misericordiae University Hospital Dublin, Dublin, Ireland
| | - Farzana Khan
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Steve Kitchen
- Dietetic Department, Birmingham Women’s & Children’s NHS Foundation Trust, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham, B4 6NH UK
| | - Karen Lang
- Ninewells Hospital Dundee, Dundee, Scotland
| | - Sharan Lowry
- Sheffield Children’s NHS Foundation Trust, Sheffield, UK
| | - Jo Males
- Aneurin Bevan University Health Board Wales, Newport, UK
| | - Georgina Martin
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | | | | | - Claire Nicol
- Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | | | - Louise Robertson
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Emma Simpson
- Royal Manchester Children’s Hospital, Manchester, UK
| | | | - Rachel Skeath
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Allyson Terry
- Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Ruth Thom
- Belfast Health & Social Care Trust, Belfast, UK
| | - Alison Tooke
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Karen vanWyk
- Royal Manchester Children’s Hospital, Manchester, UK
| | - Fiona White
- Royal Manchester Children’s Hospital, Manchester, UK
| | - Lucy White
- Sheffield Children’s NHS Foundation Trust, Sheffield, UK
| | - Anita MacDonald
- Dietetic Department, Birmingham Women’s & Children’s NHS Foundation Trust, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham, B4 6NH UK
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The Use of Glycomacropeptide in Patients with Phenylketonuria: A Systematic Review and Meta-Analysis. Nutrients 2018; 10:nu10111794. [PMID: 30453665 PMCID: PMC6266274 DOI: 10.3390/nu10111794] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 10/29/2018] [Accepted: 11/12/2018] [Indexed: 01/02/2023] Open
Abstract
In phenylketonuria (PKU), synthetic protein derived from L-amino acids (AAs) is essential in a low-phenylalanine (Phe) diet. Glycomacropeptide (GMP), an intact protein, is very low in Phe in its native form. It has been modified and adapted for PKU to provide an alternative protein source through supplementation with rate-limiting amino acids (GMP-AAs), although it still contains residual Phe. This review aims to systematically evaluate published intervention studies on the use of GMP-AAs in PKU by considering its impact on blood Phe control (primary aim) and changes in tyrosine control, nutritional biomarkers, and patient acceptability or palatability (secondary aims). Four electronic databases were searched for articles published from 2007 to June 2018. Of the 274 studies identified, only eight were included. Bias risk was assessed and a quality appraisal of the body of evidence was completed. A meta-analysis was performed with two studies with adequate comparable methodology which showed no differences between GMP-AAs and AAs for any of the interventions analysed. This work underlines the scarcity and nature of studies with GMP-AAs interventions. All were short-term with small sample sizes. There is a need for better-designed studies to provide the best evidence-based recommendations.
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24
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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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25
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Stroup BM, Ney DM, Murali SG, Rohr F, Gleason ST, van Calcar SC, Levy HL. Metabolomic Insights into the Nutritional Status of Adults and Adolescents with Phenylketonuria Consuming a Low-Phenylalanine Diet in Combination with Amino Acid and Glycomacropeptide Medical Foods. J Nutr Metab 2017; 2017:6859820. [PMID: 29464117 PMCID: PMC5804357 DOI: 10.1155/2017/6859820] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 10/23/2017] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Nutrient status in phenylketonuria (PKU) requires surveillance due to the restrictive low-Phe diet in combination with amino acid medical foods (AA-MF) or glycomacropeptide medical foods (GMP-MF). Micronutrient profiles of medical foods are diverse, and optimal micronutrient supplementation in PKU has not been established. METHODS In a crossover design, 30 participants with PKU were randomized to consume AA-MF and Glytactin™ GMP-MF in combination with a low-Phe diet for 3 weeks each. Fasting venipunctures, medical food logs, and 3-day food records were obtained. Metabolomic analyses were completed in plasma and urine by Metabolon, Inc. RESULTS The low-Phe diets in combination with AA-MF and GMP-MF were generally adequate based on Dietary Reference Intakes, clinical measures, and metabolomics. Without micronutrient supplementation of medical foods, >70% of participants would have inadequate intakes for 11 micronutrients. Despite micronutrient supplementation of medical foods, inadequate intakes of potassium in 93% of participants and choline in >40% and excessive intakes of sodium in >63% of participants and folic acid in >27% were observed. Sugar intake was excessive and provided 27% of energy. CONCLUSIONS Nutrient status was similar with AA-MF and Glytactin GMP-MF. More research related to micronutrient supplementation of medical foods for the management of PKU is needed.
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Affiliation(s)
- Bridget M. Stroup
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - Denise M. Ney
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - Sangita G. Murali
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - Frances Rohr
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sally T. Gleason
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - Sandra C. van Calcar
- Department of Molecular and Medical Genetics, School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Harvey L. Levy
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Pinto A, Almeida M, Cunha A, Carmona C, Rocha S, Guimas A, Ribeiro R, Mota C, Martins E, MacDonald A, Rocha J. Dietary management of maternal phenylketonuria with glycomacropeptide and amino acids supplements: A case report. Mol Genet Metab Rep 2017; 13:105-110. [PMID: 29085781 PMCID: PMC5650649 DOI: 10.1016/j.ymgmr.2017.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 10/10/2017] [Accepted: 10/10/2017] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In maternal PKU, protein substitute (PS) is provided by phenylalanine (PHE)-free l-amino acids (AA), but glycomacropeptide-based protein substitute (GMP) is an alternative consideration. OBJECTIVE To describe the first Portuguese Maternal Phenylketonuria (MPKU) partially managed with GMP. CASE REPORT A 31 year old MPKU female with classical PKU (mutations P281L/P281L), diagnosed by newborn screening, had a lifelong history of poor metabolic control. She has a history of partial bicornuate uterus and had a previous miscarriage in the first trimester. Pre-conception, her median blood PHE was 462 μmol/L but throughout pregnancy the median reduced to 258 μmol/L. GMP provided 30 g/day protein equivalent (46 mg/day PHE). Total protein equivalent from PS increased from 58 to 86 g/day during pregnancy but AA provided all additional protein equivalent intake. Both GMP and AA were well tolerated with no morning sickness. Normal morphologic evaluation and adequate fetal growth with cephalic biometry near the 5th percentile was determined. The infant was born at 39.3 weeks: weight 2570 g (3rd percentile), length 47.5 cm (10th percentile) and head circumference (HC) of 31.5 cm (1st percentile). In the neonatal period, the infant had craniofacial dimorphism with metopic suture prominence. Father also had bitemporal narrowing. By 12 months of age, the infant's weight (15th percentile), length (50th percentile) and HC (10th-50th percentile) were normal although bitemporal narrowing persisted. CONCLUSIONS This is the first case reporting the use of GMP in MPKU. Its PHE content did not adversely affect metabolic control although it only provided part of the PS intake. Some intrauterine development delay occurred in the last trimester, although we consider that this is unlikely to be associated with MPKU syndrome or the use of GMP. More published data is essential to examine the impact of using GMP in MPKU on morning sickness severity and aversion, maternal weight gain, blood amino acid concentrations and variability of blood PHE concentrations.
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Affiliation(s)
- A. Pinto
- Centro de Genética Médica, Centro Hospitalar do Porto (CHP), Porto, Portugal
| | - M.F. Almeida
- Centro de Genética Médica, Centro Hospitalar do Porto (CHP), Porto, Portugal
- Unit for Multidisciplinary Research in Biomedicine, Abel Salazar Institute of Biomedical Sciences, University of Porto-UMIB/ICBAS/UP, Porto, Portugal
- Centro de Referência na área de Doenças Hereditárias do Metabolismo, Centro Hospitalar do Porto - CHP, Porto, Portugal
| | - A. Cunha
- Centro de Referência na área de Doenças Hereditárias do Metabolismo, Centro Hospitalar do Porto - CHP, Porto, Portugal
| | - C. Carmona
- Centro de Genética Médica, Centro Hospitalar do Porto (CHP), Porto, Portugal
- Unit for Multidisciplinary Research in Biomedicine, Abel Salazar Institute of Biomedical Sciences, University of Porto-UMIB/ICBAS/UP, Porto, Portugal
- Centro de Referência na área de Doenças Hereditárias do Metabolismo, Centro Hospitalar do Porto - CHP, Porto, Portugal
| | - S. Rocha
- Centro de Referência na área de Doenças Hereditárias do Metabolismo, Centro Hospitalar do Porto - CHP, Porto, Portugal
| | - A. Guimas
- Centro de Referência na área de Doenças Hereditárias do Metabolismo, Centro Hospitalar do Porto - CHP, Porto, Portugal
| | - R. Ribeiro
- Centro de Referência na área de Doenças Hereditárias do Metabolismo, Centro Hospitalar do Porto - CHP, Porto, Portugal
| | - C.R. Mota
- Serviço de Cuidados Intensivos, Unidade de Neonatologia, CMIN, Centro Hospitalar do Porto - CHP, Porto, Portugal
| | - E. Martins
- Unit for Multidisciplinary Research in Biomedicine, Abel Salazar Institute of Biomedical Sciences, University of Porto-UMIB/ICBAS/UP, Porto, Portugal
- Centro de Referência na área de Doenças Hereditárias do Metabolismo, Centro Hospitalar do Porto - CHP, Porto, Portugal
| | - A. MacDonald
- Birmingham Women's and Children's Hospital, Birmingham, UK
| | - J.C. Rocha
- Centro de Genética Médica, Centro Hospitalar do Porto (CHP), Porto, Portugal
- Centro de Referência na área de Doenças Hereditárias do Metabolismo, Centro Hospitalar do Porto - CHP, Porto, Portugal
- Faculdade de Ciências da Saúde, Universidade Fernando Pessoa, Portugal
- Centre for Health Technology and Services Research (CINTESIS), Portugal
- Corresponding author at: Centro de Genética Médica, Centro Hospitalar do Porto – CHP, Praça Pedro Nunes, 88, 4099-028 Porto, Portugal.Centro de Genética Médica, Centro Hospitalar do Porto – CHPPraça Pedro Nunes, 88Porto4099-028Portugal
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