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González-Lamuño D, Arrieta-Blanco FJ, Fuentes ED, Forga-Visa MT, Morales-Conejo M, Peña-Quintana L, Vitoria-Miñana I. Hyperhomocysteinemia in Adult Patients: A Treatable Metabolic Condition. Nutrients 2023; 16:135. [PMID: 38201964 PMCID: PMC10780827 DOI: 10.3390/nu16010135] [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: 11/20/2023] [Revised: 12/26/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
Hyperhomocysteinemia (HHcy) is recognized as an independent risk factor for various significant medical conditions, yet controversy persists around its assessment and management. The diagnosis of disorders afffecting homocysteine (Hcy) metabolism faces delays due to insufficient awareness of its clinical presentation and unique biochemical characteristics. In cases of arterial or venous thrombotic vascular events, particularly with other comorbidities, it is crucial to consider moderate to severe HHcy. A nutritional approach to HHcy management involves implementing dietary strategies and targeted supplementation, emphasizing key nutrients like vitamin B6, B12, and folate that are crucial for Hcy conversion. Adequate intake of these vitamins, along with betaine supplementation, supports Hcy remethylation. Lifestyle modifications, such as smoking cessation and regular physical activity, complement the nutritional approach to enhance Hcy metabolism. For individuals with HHcy, maintaining a plasma Hcy concentration below 50 μmol/L consistently is vital to lowering the risk of vascular events. Collaboration with healthcare professionals and dietitians is essential for developing personalized dietary plans addressing the specific needs and underlying health conditions. This integrated approach aims to optimize metabolic processes and reduce the associated health risks.
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Affiliation(s)
| | | | - Elena Dios Fuentes
- Endocrinology and Nutrition Department, Virgen del Rocío University Hospital, 41013 Sevilla, Spain;
| | | | - Monstserrat Morales-Conejo
- Unit for Congenital Metabolic Diseases and Other Rare Diseases, Internal Medicine Department, 12 de Octubre University Hospital, 28041 Madrid, Spain;
| | - Luis Peña-Quintana
- Pediatric Gastroenterology and Nutrition Unit, Insular Materno-Infantil University Hospital Complex, Asociación Canaria de Investigación Pediátrica, Centro de Investigación Biomédica en Red de la Fisiopatología de la Obesidad y Nutrición, University of Las Palmas de Gran Canaria, 35016 Las Palmas de Gran Canaria, Spain;
| | - Isidro Vitoria-Miñana
- Nutrition and Metabolic Diseases Unit, La Fe University Hospital, 46026 Valencia, Spain
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2
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Ziegler SG, Kim J, Ehmsen JT, Vernon HJ. Inborn errors of amino acid metabolism - from underlying pathophysiology to therapeutic advances. Dis Model Mech 2023; 16:dmm050233. [PMID: 37994477 PMCID: PMC10690057 DOI: 10.1242/dmm.050233] [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: 04/06/2023] [Accepted: 10/19/2023] [Indexed: 11/24/2023] Open
Abstract
Amino acids are organic molecules that serve as basic substrates for protein synthesis and have additional key roles in a diverse array of cellular functions, including cell signaling, gene expression, energy production and molecular biosynthesis. Genetic defects in the synthesis, catabolism or transport of amino acids underlie a diverse class of diseases known as inborn errors of amino acid metabolism. Individually, these disorders are rare, but collectively, they represent an important group of potentially treatable disorders. In this Clinical Puzzle, we discuss the pathophysiology, clinical features and management of three disorders that showcase the diverse clinical presentations of disorders of amino acid metabolism: phenylketonuria, lysinuric protein intolerance and homocystinuria due to cystathionine β-synthase (CBS) deficiency. Understanding the biochemical perturbations caused by defects in amino acid metabolism will contribute to ongoing development of diagnostic and management strategies aimed at improving the morbidity and mortality associated with this diverse group of disorders.
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Affiliation(s)
- Shira G. Ziegler
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Jiyoung Kim
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Jeffrey T. Ehmsen
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Hilary J. Vernon
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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3
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Kakaje A, Fadel A, Hosam Aldeen O, Hamdan O. Priapism in a Child from Homocystinuria from Methylenetetrahydrofolate Reductase MTHFR (C677T) Mutation. Case Rep Urol 2023; 2023:2263341. [PMID: 37485311 PMCID: PMC10359136 DOI: 10.1155/2023/2263341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 06/03/2023] [Accepted: 06/30/2023] [Indexed: 07/25/2023] Open
Abstract
Priapism is a prolonged involuntary erection that can have severe complications if left untreated. Ischaemic priapism is very rare in children and requires urgent intervention to prevent permanent erectile dysfunction and penile shortening. It can be caused by ischaemia in sickle cell anaemia, leukaemia, trauma, drugs, or idiopathy. Homocystinuria is a rare autosomal recessive disorder that can cause hyperhomocysteinemia and hypercoagulability. Very few reports suggested that priapism can be caused by hyperhomocysteinemia, and they were in adults. However, we present the first of such a case to the best of our knowledge of a prepubescent child who only had the MTHFR (C677T) mutation that causes homocystinuria and had ischaemic priapism. A nine-year-old Syrian Arab boy was presented with priapism that lasted for a few hours. Blood tests show normal blood count, film, and haemoglobin electrophoresis. However, prothrombin time, partial thromboplastin time, homocysteine level, and C-reactive protein were elevated. Other coagulation tests were within the normal range. Doppler ultrasonography found decreased cavernous blood flow, and warm 0.9% saline lavage of the cavernosa was indicated and successfully treated the priapism. Genetic testing for the homozygous MTHFR (C677T) mutation was later confirmed, and warfarin was indicated. In conclusion, homocystinuria is very rare in priapism, and this is the first case to report this phenomenon in a child. Ultrasonography in low-income countries is an essential tool that helps identify a wide variety of medical conditions such as priapism and can be successfully managed by aspiration with warm saline.
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Affiliation(s)
- Ameer Kakaje
- Faculty of Medicine, Damascus University, Damascus, Syria
- University Hospital Geelong, Barwon Health, Victoria, Australia
| | - Ammar Fadel
- Faculty of Medicine, Damascus University, Damascus, Syria
- Redcliffe Hospital, Metro North Health, Queensland, Australia
| | | | - Othman Hamdan
- Faculty of Medicine, Damascus University, Damascus, Syria
- Department of Haematology, Children's University Hospital, Damascus University, Damascus, Syria
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ALSolami AA, Almalki AA, Alhedyan SY, Alghamdi A, Alzahrani SM, Dause WR, Hamdi FA, Howladar MT, Ibrahim IA. Plasma Homocysteine Levels and Cardiovascular Events in Patients With End-Stage Renal Disease: A Systematic Review. Cureus 2023; 15:e40357. [PMID: 37456428 PMCID: PMC10339662 DOI: 10.7759/cureus.40357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Patients with chronic renal disease or failure are at a heightened risk of mortality due to cardiovascular disease (CVD), which is a predominant cause of death in this population. Hyperhomocysteinemia is prevalent in patients with end-stage renal disease (ESRD), which may increase their susceptibility to CVD. METHODS We conducted a comprehensive search of PubMed, Science Direct, and Google Scholar for articles published between 2003 and February 2023, using a combination of keywords such as "plasma homocysteine levels," "hyperhomocysteinemia," "end-stage renal disease," "renal failure," "kidney failure," "cardiovascular events," "cardiovascular disease," "myocardial infarction," "coronary artery disease," and "stroke." Our inclusion criteria were studies that investigated the association between total homocysteine (Hcy) level and CVD or total mortality, as well as the impact of vitamin supplementation on cardiovascular or mortality risk. We restricted our search to English-language studies that included ESRD patients and provided data on plasma Hcy levels and associated CVD events. RESULTS This systematic review includes 11 articles published between 2003 and 2023 that enrolled a total of 3,953 subjects, of whom 79.15% were male patients. All studies included in the review were either quantitative randomized trials or non-randomized studies, such as cross-sectional, cohort, or case-control studies. Of the total studies included, 10 reported either cardiovascular mortality or CVD events, including cardiovascular death, myocardial infarction (MI), angina, and stroke. One study reported the CVD risk score of the patients, and most of them had higher total homocysteine (tHcy) levels. Overall, a total of 817 CVD events were reported across the studies. CONCLUSION In conclusion, the relationship between Hcy and cardiovascular events in ESRD patients is not straightforward and requires further research. However, our review suggests that Hcy could be a predictor of cardiovascular events in this population, and its nutritional characteristics as well as other associated comorbidities may contribute to its inverse association with outcomes.
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Affiliation(s)
| | | | | | | | | | - Wesam R Dause
- Cardiology, King Fahad Armed Forces Hospital, Jeddah, SAU
| | - Fahad A Hamdi
- Cardiology, King Fahad Armed Forces Hospital, Jeddah, SAU
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Nitrous oxide abuse leading to extreme homocysteine levels and thrombosis in young adults: a case series. JOURNAL OF THROMBOSIS AND HAEMOSTASIS : JTH 2023; 21:276-283. [PMID: 36700505 DOI: 10.1016/j.jtha.2022.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 09/09/2022] [Accepted: 10/17/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Neurologic complications from recreational use of nitrous oxide (N2O), which are attributed to vitamin B12 deficiency, have been well documented. With increasing dosages and frequency of N2O use, an additional association with thromboembolisms is becoming apparent. OBJECTIVES To assess thrombotic complications of recreational N2O use. METHODS All medical charts at the largest hospital in Amsterdam were searched for N2O use and subsequent neurologic and/or thrombotic events. For patients with thrombotic events, we extracted data on the risk factors for arterial and venous thrombosis as well as serum vitamin B12 and homocysteine concentrations. RESULTS Between January 2015 and May 2021, 326 patients who reported recreational use of N2O were identified; of these, 17 (5%) patients presented with severe thrombotic events associated with N2O (71% men; median age, 26 years [range, 18-53 years]), 5 patients presented with arterial thrombosis (3 with acute coronary syndrome, 1 with femoral artery thrombosis, and 1 with middle cerebral artery thrombus), and 12 patients presented with venous thromboembolisms (10 with pulmonary embolisms, 1 with portal vein thrombosis and 1 with cerebral vein thrombosis). Additionally, homocysteine were concentrations severely increased (median, 125 μmol/L [range, 22-253 μmol/L]; reference, <15 μmol/L). Patients reported use of 400 to 6000 g (ie, 50-750 balloons) of N2O in 1 day. Fifty percent of these patients had experienced neurologic symptoms before the thrombotic event. CONCLUSION We describe an alarming incidence of serious thrombotic events among young adults after excessive recreational use of N2O, accompanied by extremely high homocysteine concentrations. The upward trend in the recreational use of N2O warrants more awareness of its dangers among both users and medical professionals. Furthermore, these findings could reopen the discussion on possible associations between hyperhomocysteinemia and thrombosis mediated through N2O.
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Song JH, Huh H, Bae E, Lee J, Lee JP, Lee JS, Kim GS, Yoo KD. Association between homocysteinemia and mortality in CKD: A propensity-score matched analysis using NHANES-National Death Index. Medicine (Baltimore) 2022; 101:e30334. [PMID: 36086712 PMCID: PMC10980502 DOI: 10.1097/md.0000000000030334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 07/19/2022] [Indexed: 11/27/2022] Open
Abstract
Hyperhomocysteinemia (HHcy) is considered a risk factor for cardiovascular disease (CVD), including chronic kidney disease (CKD). In this study, we investigated the association between levels of serum homocysteine (Hcy) and mortality, inferred from the presence of CKD. Our study included data of 9895 participants from the 1999 to 2016 National Health and Nutrition Examination Surveys (NHANES). Multivariable-adjusted Cox proportional hazard models using propensity-score, were used to examine dose-response associations between Hcy level and mortality. A total of 9895 participants, 1025 (10.3%) participants were diagnosed with CKD. In a multivariate Cox regression analysis including all participants, Hcy level was significantly associated with all-cause mortality in the nonCKD group, compared to the 1st quartile in the fully adjusted model (2nd quartile: hazard ratio (HR) 1.75, 95% confidence interval (CI) 1.348-2.274, P < .001; 3rd quartile: HR 2.22, 95% CI 1.726-2.855, P < .001; 4th quartile: HR 3.77, 95% CI 2.952-4.830, P < .001). However, this finding was not observed in the CKD group. The observed pattern was similar after propensity score matching. In the nonCKD group, overall mortality increased in proportion to Hcy concentration (2nd quartile: HR 2.19, 95% CI 1.299-3.709, P = .003; 3rd quartile: HR 2.60, 95% CI 1.570-4.332, P < .001; 4th quartile: HR 3.72, 95% CI 2.254-6.139, P < .001). However, the risk of all-cause mortality according to the quartile of Hcy level, did not increase in the CKD group. This study found a correlation between the Hcy level and mortality rate only in the nonCKD group. These altered risk factor patterns may be attributed to protein-energy wasting or chronic inflammation status, that is accompanied by CKD.
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Affiliation(s)
- Je Hun Song
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Hyuk Huh
- Department of Internal Medicine, Pusan Paik Hospital, Inje University College of Medicine, Busan, South Korea
| | - Eunjin Bae
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Jeonghwan Lee
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Jung Pyo Lee
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Jong Soo Lee
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Gwang Sil Kim
- Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, South Korea
| | - Kyung Don Yoo
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
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7
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Kuipers RS, Paes AJ, Amoroso G, Riezebos RK. Thrombosis within the left anterior descending coronary artery and left ventricle after high-dose nitrous oxide use. BMJ Case Rep 2022; 15:e248281. [PMID: 35589263 PMCID: PMC9121436 DOI: 10.1136/bcr-2021-248281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2022] [Indexed: 11/04/2022] Open
Abstract
We present a man in his 30s with acute anterior myocardial infarction due to thrombotic occlusion of the left anterior descending artery and subsequent left ventricular thrombus formation after high-dose recreational use of nitrous oxide (N2O). Initial questioning for use of illicit substances was negative, but low vitamin B12 levels and severely elevated homocysteine levels prompted us to interrogate for the use of laughing gas. On questioning, the patient admitted to have used this substance, which he presumed to be innocent. Neither percutaneous coronary intervention with balloon dilatation nor intravenous glycoprotein IIb/IIIa receptor antagonist, nor continuous use of anticoagulation and double antiplatelet therapy resulted in thrombus resolution. Due to a severely reduced left ventricular function, despite 3 months on heart failure therapy, the patient is being counselled for intracardiac defibrillator implantation. We conclude that N2O, notably when consumed in conjunction with other proatherogenic substances, is associated with thrombosis: a relation possibly mediated by severe hyperhomocysteinaemia.
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Affiliation(s)
| | - Aron J Paes
- Cardiology, OLVG, Amsterdam, The Netherlands
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8
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Cucchiara BL, Kasner SE. Treatment of “Other” Stroke Etiologies. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00058-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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9
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Diagnosis and Management of Inborn Errors of Metabolism in Adult Patients in the Emergency Department. Diagnostics (Basel) 2021; 11:diagnostics11112148. [PMID: 34829496 PMCID: PMC8621113 DOI: 10.3390/diagnostics11112148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 11/12/2021] [Accepted: 11/16/2021] [Indexed: 12/30/2022] Open
Abstract
Inborn errors of metabolism (IEM) constitute an important group of conditions characterized by an altered metabolic pathway. There are numerous guidelines for the diagnosis and management of IEMs in the pediatric population but not for adults. Given the increasing frequency of this group of conditions in adulthood, other clinicians in addition to pediatricians should be aware of them and learn to identify their characteristic manifestations. Early recognition and implementation of an appropriate therapeutic approach would improve the clinical outcome of many of these patients. This review presents when and how to investigate a metabolic disorder with the aim of encouraging physicians not to overlook a treatable disorder.
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10
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Hart C, McNulty J, Cotter M, Al Jasmi F, Crushell E, Monavari AA. The challenges of pregnancy management in pyridoxine nonresponsive homocystinuria: The Irish experience. JIMD Rep 2021; 61:34-41. [PMID: 34485015 PMCID: PMC8411100 DOI: 10.1002/jmd2.12233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 05/12/2021] [Accepted: 05/17/2021] [Indexed: 11/08/2022] Open
Abstract
Many patients with inborn errors of metabolism, due to early diagnosis and improved management, are living longer with less disease burden. Several are now having families of their own. This poses challenges both for the metabolic control of the mother and potential secondary effects on the fetus, as well as the risk of inheriting the inborn error. Classical homocystinuria (HCU, OMIM 236200) is a rare multisystem condition with intellectual, skeletal, ocular, and thromboembolic complications. Ireland has included HCU in the National Newborn Bloodspot Screening Program since 1971. The European network and registry for homocystinurias and methylation defects (E-HOD) guidelines outline the requirements for management and monitoring of this condition and associated complications. Pregnancy alone has many potential complications. When combined with an underlying condition such as HCU, which is prothrombotic and requires a highly medicalized diet, there are significantly increased risks to both mother and baby. Colleagues previously published an Irish case of maternal HCU with successful pregnancy outcome. We add five pregnancies to two women with classical HCU to the literature. We use these to highlight the importance of careful metabolic control and managing the predictable HCU associated risks during pregnancy and the postpartum period. Our cases demonstrate the potential for healthy pregnancies in HCU and that this is best achieved with a motivated clinical team and good patient engagement. Only small numbers of pregnancies in HCU have been reported and we are still learning best practice, but proactive management is essential, as in any inborn error of metabolism.
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Affiliation(s)
- Caroline Hart
- Paediatric Metabolic Department, Royal Belfast Hospital for Sick ChildrenBelfastUK
| | - Jenny McNulty
- National Centre for Inherited Metabolic Disorders, Children's Health Ireland at Temple StreetDublinIreland
| | - Melanie Cotter
- Paediatric Haematology, Children's Health Ireland at Temple StreetDublinIreland
| | - Fatima Al Jasmi
- Department of Pediatrics, Tawam HospitalAl AinUnited Arab Emirates
| | - Ellen Crushell
- National Centre for Inherited Metabolic Disorders, Children's Health Ireland at Temple StreetDublinIreland
- University College DublinDublinIreland
| | - Ahmad Ardeshir Monavari
- National Centre for Inherited Metabolic Disorders, Children's Health Ireland at Temple StreetDublinIreland
- University College DublinDublinIreland
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11
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Gupta S, Wang L, Slifker MJ, Cai KQ, Maclean KN, Wasek B, Bottiglieri T, Kruger WD. Analysis of differential neonatal lethality in cystathionine β-synthase deficient mouse models using metabolic profiling. FASEB J 2021; 35:e21629. [PMID: 33949005 DOI: 10.1096/fj.202100302r] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/06/2021] [Accepted: 04/13/2021] [Indexed: 12/14/2022]
Abstract
Cystathionine beta-synthase (CBS) is a key enzyme of the trans-sulfuration pathway that converts homocysteine to cystathionine. Loss of CBS activity due to mutation results in CBS deficiency, an inborn error of metabolism characterized by extreme elevation of plasma total homocysteine (tHcy). C57BL6 mice containing either a homozygous null mutation in the cystathionine β-synthase (Cbs-/- ) gene or an inactive human CBS protein (Tg-G307S Cbs-/- ) are born in mendelian numbers, but the vast majority die between 18 and 21 days of age due to liver failure. However, adult Cbs null mice that express a hypomorphic allele of human CBS as a transgene (Tg-I278T Cbs-/- ) show almost no neonatal lethality despite having serum tHcy levels similar to mice with no CBS activity. Here, we characterize liver and serum metabolites in neonatal Cbs+/- , Tg-G307S Cbs-/- , and Tg-I278T Cbs-/- mice at 6, 10, and 17 days of age to understand this difference. In serum, we observe similar elevations in tHcy in both Tg-G307S Cbs-/- and Tg-I278T Cbs-/- compared to control animals, but methionine is much more severely elevated in Tg-G307S Cbs-/- mice. Large scale metabolomic analysis of liver tissue confirms that both methionine and methionine-sulfoxide are significantly more elevated in Tg-G307S Cbs-/- animals, along with significant differences in several other metabolites including hexoses, amino acids, other amines, lipids, and carboxylic acids. Our data are consistent with a model that the neonatal lethality observed in CBS-null mice is driven by excess methionine resulting in increased stress on a variety of related pathways including the urea cycle, TCA cycle, gluconeogenesis, and phosphatidylcholine biosynthesis.
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Affiliation(s)
- Sapna Gupta
- Cancer Biology Program, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Liqun Wang
- Cancer Biology Program, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Michael J Slifker
- Biostatistics and Bioinformatics Facility, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Kathy Q Cai
- Cancer Biology Program, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Kenneth N Maclean
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Brandi Wasek
- Center of Metabolomics, Institute of Metabolic Disease, Baylor Scott & White Research Institute, Dallas, TX, USA
| | - Teodoro Bottiglieri
- Center of Metabolomics, Institute of Metabolic Disease, Baylor Scott & White Research Institute, Dallas, TX, USA
| | - Warren D Kruger
- Cancer Biology Program, Fox Chase Cancer Center, Philadelphia, PA, USA
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12
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Prasad N, Hamosh A, Sponseller P. Orthopaedic Manifestations of Inborn Errors of Metabolism. JBJS Rev 2021; 9:01874474-202107000-00003. [PMID: 34257233 DOI: 10.2106/jbjs.rvw.20.00245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Inborn errors of metabolism are disorders of carbohydrate, amino acid, organic acid, or purine and pyrimidine metabolism; disorders of fatty acid oxidation; disorders of metal metabolism; and lysosomal storage defects that can cause metabolic derangements that have secondary musculoskeletal effects. » Orthopaedic surgeons should be aware that patients with inborn errors of metabolism may be at high risk for spasticity, which may cause joint subluxations, scoliosis, and contractures, as well as poor bone quality, which is caused by malnutrition or disordered bone growth. » Multidisciplinary care and follow-up are important to identify musculoskeletal problems in a timely manner in order to provide effective treatment.
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Affiliation(s)
- Niyathi Prasad
- Departments of Orthopaedic Surgery and Genetic Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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13
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Hou Y, Guo W, Fan T, Li B, Ge W, Gao R, Wang J. Advanced Research of Abdominal Aortic Aneurysms on Metabolism. Front Cardiovasc Med 2021; 8:630269. [PMID: 33614752 PMCID: PMC7892590 DOI: 10.3389/fcvm.2021.630269] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/05/2021] [Indexed: 01/16/2023] Open
Abstract
Abdominal aortic aneurysm (AAA) is a cardiovascular disease with a high risk of death, seriously threatening the life and health of people. The specific pathogenesis of AAA is still not fully understood. In recent years, researchers have found that amino acid, lipid, and carbohydrate metabolism disorders play important roles in the occurrence and development of AAA. This review is aimed to summarize the latest research progress of the relationship between AAA progression and body metabolism. The body metabolism is closely related to the occurrence and development of AAA. It is necessary to further investigate the pathogenesis of AAA from the perspective of metabolism to provide theoretical basis for AAA diagnosis and drug development.
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Affiliation(s)
- Yangfeng Hou
- State Key Laboratory of Medical Molecular Biology, Institute of Basic Medicine, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Wenjun Guo
- State Key Laboratory of Medical Molecular Biology, Institute of Basic Medicine, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Tianfei Fan
- State Key Laboratory of Medical Molecular Biology, Institute of Basic Medicine, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Bolun Li
- State Key Laboratory of Medical Molecular Biology, Institute of Basic Medicine, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Weipeng Ge
- State Key Laboratory of Medical Molecular Biology, Institute of Basic Medicine, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Ran Gao
- State Key Laboratory of Medical Molecular Biology, Institute of Basic Medicine, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Jing Wang
- State Key Laboratory of Medical Molecular Biology, Institute of Basic Medicine, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
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14
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Ferreira CR, Blau N. Clinical and biochemical footprints of inherited metabolic diseases. IV. Metabolic cardiovascular disease. Mol Genet Metab 2021; 132:112-118. [PMID: 33388235 PMCID: PMC7867625 DOI: 10.1016/j.ymgme.2020.12.290] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/16/2020] [Accepted: 12/16/2020] [Indexed: 12/12/2022]
Abstract
Inherited metabolic diseases account for 15-20% of all cases of pediatric cardiomyopathy, with a high mortality of 15-47%. Metabolic diseases can also commonly be associated with other types of cardiovascular involvement such as arrhythmias, valvulopathy or vasculopathy. We reviewed and updated the list of known metabolic etiologies associated with cardiovascular involvement, and found 246 relevant inborn errors of metabolism. This represents the fourth of a series of articles attempting to create and maintain a comprehensive list of clinical and metabolic differential diagnoses according to system involvement.
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Affiliation(s)
- Carlos R Ferreira
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA.
| | - Nenad Blau
- Division of Metabolism, University Children's Hospital, Zürich, Switzerland.
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Kerkvliet SP, Rheault MN, Berry SA. Liver transplant as a curative treatment in a pediatric patient with classic homocystinuria: A case report. Am J Med Genet A 2021; 185:1247-1250. [PMID: 33443292 DOI: 10.1002/ajmg.a.62076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 12/19/2020] [Accepted: 12/24/2020] [Indexed: 11/10/2022]
Abstract
We report a patient with homocystinuria and hyperoxaluria who was cured of homocystinuria-related disease following liver transplant. The patient was diagnosed with homocystinuria as a newborn and was treated with dietary modifications and supplements. At 22 months, he passed a calcium oxalate stone and was found to have numerous bilateral kidney stones. Genetic testing confirmed primary hyperoxaluria, type 1. He underwent preemptive liver transplant at age four to treat primary hyperoxaluria. Following transplant, his serum methionine and homocysteine levels normalized, thus, demonstrating resolution of homocystinuria. Methionine and homocysteine levels remained normal 6 years later. Homocystinuria is associated with ophthalmologic, skeletal, neurologic, and thromboembolic complications. As cystathionine beta-synthase resides in the liver, transplant was hypothesized to be an effective treatment. Primary hyperoxaluria generally progresses to chronic kidney disease and is treated with combined kidney-liver transplant at the time of end stage kidney disease. Given this patient's dual diagnoses, we proceeded with preemptive liver transplantation. Three prior cases of patients with homocystinuria treated with liver transplantation have been reported. In all cases, transplant resolved metabolic effects. However, our case represents a pediatric patient without disease-related complications prior to transplant. This case supports liver-targeted gene therapies as an effective treatment for homocystinuria.
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Affiliation(s)
- Stephanie P Kerkvliet
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Michelle N Rheault
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Susan A Berry
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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16
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The Cost-Effectiveness of Expanding the UK Newborn Bloodspot Screening Programme to Include Five Additional Inborn Errors of Metabolism. Int J Neonatal Screen 2020; 6:ijns6040093. [PMID: 33233828 PMCID: PMC7711627 DOI: 10.3390/ijns6040093] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/12/2020] [Accepted: 11/13/2020] [Indexed: 11/17/2022] Open
Abstract
Glutaric aciduria type 1, homocystinuria, isovaleric acidaemia, long-chain hydroxyacyl CoA dehydrogenase deficiency and maple syrup urine disease are all inborn errors of metabolism that can be detected through newborn bloodspot screening. This evaluation was undertaken in 2013 to provide evidence to the UK National Screening Committee for the cost-effectiveness of including these five conditions in the UK Newborn Bloodspot Screening Programme. A decision-tree model with lifetable estimates of outcomes was built with the model structure and parameterisation informed by a systematic review and expert clinical judgment. A National Health Service/Personal Social Services perspective was used, and lifetime costs and quality-adjusted life years (QALYs) were discounted at 1.5%. Uncertainty in the results was explored using expected value of perfect information analysis methods together with a sensitivity analysis using the screened incidence rate in the UK from 2014 to 2018. The model estimates that screening for all the conditions is more effective and cost saving when compared to not screening for each of the conditions, and the results were robust to the updated incidence rates. The key uncertainties included the sensitivity and specificity of the screening test and the estimated costs and QALYs.
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17
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Kožich V, Stabler S. Lessons Learned from Inherited Metabolic Disorders of Sulfur-Containing Amino Acids Metabolism. J Nutr 2020; 150:2506S-2517S. [PMID: 33000152 DOI: 10.1093/jn/nxaa134] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/12/2020] [Accepted: 04/17/2020] [Indexed: 12/16/2022] Open
Abstract
The metabolism of sulfur-containing amino acids (SAAs) requires an orchestrated interplay among several dozen enzymes and transporters, and an adequate dietary intake of methionine (Met), cysteine (Cys), and B vitamins. Known human genetic disorders are due to defects in Met demethylation, homocysteine (Hcy) remethylation, or cobalamin and folate metabolism, in Hcy transsulfuration, and Cys and hydrogen sulfide (H2S) catabolism. These disorders may manifest between the newborn period and late adulthood by a combination of neuropsychiatric abnormalities, thromboembolism, megaloblastic anemia, hepatopathy, myopathy, and bone and connective tissue abnormalities. Biochemical features include metabolite deficiencies (e.g. Met, S-adenosylmethionine (AdoMet), intermediates in 1-carbon metabolism, Cys, or glutathione) and/or their accumulation (e.g. S-adenosylhomocysteine, Hcy, H2S, or sulfite). Treatment should be started as early as possible and may include a low-protein/low-Met diet with Cys-enriched amino acid supplements, pharmacological doses of B vitamins, betaine to stimulate Hcy remethylation, the provision of N-acetylcysteine or AdoMet, or experimental approaches such as liver transplantation or enzyme replacement therapy. In several disorders, patients are exposed to long-term markedly elevated Met concentrations. Although these conditions may inform on Met toxicity, interpretation is difficult due to the presence of additional metabolic changes. Two disorders seem to exhibit Met-associated toxicity in the brain. An increased risk of demyelination in patients with Met adenosyltransferase I/III (MATI/III) deficiency due to biallelic mutations in the MATIA gene has been attributed to very high blood Met concentrations (typically >800 μmol/L) and possibly also to decreased liver AdoMet synthesis. An excessively high Met concentration in some patients with cystathionine β-synthase deficiency has been associated with encephalopathy and brain edema, and direct toxicity of Met has been postulated. In summary, studies in patients with various disorders of SAA metabolism showed complex metabolic changes with distant cellular consequences, most of which are not attributable to direct Met toxicity.
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Affiliation(s)
- Viktor Kožich
- Department of Pediatrics and Adolescent Medicine, Charles University-First Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Sally Stabler
- Department of Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, USA
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18
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High prevalence of cerebral venous sinus thrombosis in seven Chinese patients with cystathionine β-synthase deficiency. Chin Med J (Engl) 2020; 133:2247-2249. [PMID: 32769498 PMCID: PMC7508451 DOI: 10.1097/cm9.0000000000001013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Yamada K, Yokoyama K, Aoki K, Taketani T, Yamaguchi S. Long-Term Outcomes of Adult Patients with Homocystinuria before and after Newborn Screening. Int J Neonatal Screen 2020; 6:ijns6030060. [PMID: 33239586 PMCID: PMC7569964 DOI: 10.3390/ijns6030060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/23/2020] [Accepted: 07/29/2020] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Homocystinuria (HCU) is a rare inherited metabolic disease. In Japan, newborn screening (NBS) for HCU (cystathionine β-synthase deficiency) was initiated in 1977. We compared the outcomes between patients detected by NBS (NBS group) and clinically detected patients (non-NBS group). METHODS We administered questionnaires about clinical symptoms and social conditions to 16 attending physicians of 19 adult HCU patients treated with methionine-free formula. RESULTS Eighteen patients (nine patients each in the NBS and non-NBS groups) participated. The frequency of patients with ocular, vascular, central nervous system, and skeletal symptoms in the NBS group was lower than that in the non-NBS group. Intellectual disability was observed in one and eight patients in the NBS and non-NBS groups, respectively. Concerning their social conditions, all patients in the NBS group were employed or still attending school, while only two patients in the non-NBS group were employed. Three of the four patients who discontinued treatment presented some symptoms, even in the NBS group. CONCLUSION The social and intellectual outcomes of adult Japanese patients with HCU detected by NBS were favorable. However, even in the patients in the NBS group, some symptoms might not be preventable without continuous treatment.
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Affiliation(s)
- Kenji Yamada
- Department of Pediatrics, Shimane University Faculty of Medicine, 89-1, En-ya-cho, Izumo, Shimane 693-8501, Japan; (T.T.); (S.Y.)
- Correspondence: ; Tel.: +81-853-20-2219; Fax: +81-853-20-2215
| | - Kazunori Yokoyama
- Secretariat of Special Formula, Aiiku Maternal and Child Health Center, Imperial Gift Foundation Boshi-Aiiku-Kai, 5-6-8, Minami Asabu, Minato-ku, Tokyo 106-8580, Japan; (K.Y.); (K.A.)
| | - Kikumaro Aoki
- Secretariat of Special Formula, Aiiku Maternal and Child Health Center, Imperial Gift Foundation Boshi-Aiiku-Kai, 5-6-8, Minami Asabu, Minato-ku, Tokyo 106-8580, Japan; (K.Y.); (K.A.)
| | - Takeshi Taketani
- Department of Pediatrics, Shimane University Faculty of Medicine, 89-1, En-ya-cho, Izumo, Shimane 693-8501, Japan; (T.T.); (S.Y.)
| | - Seiji Yamaguchi
- Department of Pediatrics, Shimane University Faculty of Medicine, 89-1, En-ya-cho, Izumo, Shimane 693-8501, Japan; (T.T.); (S.Y.)
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Park I, Johnson LK, Cox A, Branchford BR, Paola JD, Bublil EM, Majtan T. Hypermethioninemia Leads to Fatal Bleeding and Increased Mortality in a Transgenic I278T Mouse Model of Homocystinuria. Biomedicines 2020; 8:biomedicines8080244. [PMID: 32722248 PMCID: PMC7459533 DOI: 10.3390/biomedicines8080244] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 07/17/2020] [Accepted: 07/22/2020] [Indexed: 01/20/2023] Open
Abstract
Severely elevated plasma homocysteine and methionine lead to thromboembolic events and strokes in homocystinuric (HCU) patients. Mouse models of HCU failed to exhibit prothrombotic phenotype, presumably due to lack of hypermethioninemia. We evaluated the impact of hypermethioninemia together with hyperhomocysteinemia on murine HCU phenotype and compared the efficacy of the current and novel therapies for HCU. High methionine intake decreased survival of I278T mice, which died from intestinal bleeding with hepatic and pancreatic failure. I278T mice on normal or increased methionine intake developed endothelial dysfunction, but paradoxically demonstrated delayed occlusion in an induced arterial thrombosis model. RNA-seq analysis suggested that expression of coagulation factor XI (FXI) is downregulated in livers of I278T mice. Indeed, plasma concentrations of FXI were decreased in I278T mice on normal diet and further reduced by increased methionine intake. Dietary methionine restriction normalized the observed phenotype. Similarly, treatment with OT-58, a novel enzyme therapy for HCU, corrected the phenotype in I278T mice regardless of their dietary methionine intake. Hypermethioninemia does not contribute to prothrombotic phenotype in murine HCU. Downregulation of FXI may contribute to the lack of prothrombotic tendency in I278T mice. Methionine restriction or treatment with OT-58 corrects vascular disease in the I278T mouse model of HCU.
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Affiliation(s)
- Insun Park
- Section of Genetics & Metabolism, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA;
| | - Linda K. Johnson
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA;
| | - Allaura Cox
- Section of Hematology/Oncology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045, USA; (A.C.); (B.R.B.); (J.D.P.)
- University of Colorado Hemophilia and Thrombosis Center, Aurora, CO 80045, USA
| | - Brian R. Branchford
- Section of Hematology/Oncology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045, USA; (A.C.); (B.R.B.); (J.D.P.)
- University of Colorado Hemophilia and Thrombosis Center, Aurora, CO 80045, USA
| | - Jorge Di Paola
- Section of Hematology/Oncology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045, USA; (A.C.); (B.R.B.); (J.D.P.)
- University of Colorado Hemophilia and Thrombosis Center, Aurora, CO 80045, USA
| | | | - Tomas Majtan
- Section of Genetics & Metabolism, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA;
- Correspondence: ; Tel.: +1-303-724-3813
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21
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Park I, Hůlková H, Krijt J, Kožich V, Bublil EM, Majtan T. Long-term uninterrupted enzyme replacement therapy prevents liver disease in murine model of severe homocystinuria. Hum Mutat 2020; 41:1662-1670. [PMID: 32623804 DOI: 10.1002/humu.24072] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/16/2020] [Accepted: 07/02/2020] [Indexed: 11/09/2022]
Abstract
Classical homocystinuria (HCU) is an inborn error of metabolism caused by loss of cystathionine β-synthase (CBS) activity with the concomitant buildup of homocysteine. In knockout (KO) mice, a mouse model of HCU, complete lack of CBS is neonatally lethal. Administration of OT-58, an enzyme therapy for HCU, during the first 5 weeks of life rescued KO mice survival by preventing liver disease. Here, we studied the impact of a long-term uninterrupted OT-58 treatment or its absence beyond the neonatal period on liver pathology and metabolism. Plasma and liver metabolites of KO mice on OT-58 treatment were substantially improved or normalized compared with those receiving vehicle. Increased plasma activities of alanine aminotransferase and aspartate aminotransferase of vehicle-injected KO mice suggested the progression of liver damage with age and lack of treatment. At 3 months of age, liver histology showed no signs of hepatopathy in both vehicle- and OT-58-treated KO mice. However, moderate to severe liver disease, characterized by steatosis, hepatocellular necroses, disorganized endoplasmic reticulum, and swollen mitochondria, developed in 6-month-old vehicle-injected KO mice. KO mice on OT-58 treatment remained asymptomatic and were indistinguishable from age-matched healthy controls. Long-term uninterrupted OT-58 treatment was essential to prevent severe liver disease in the KO mouse model of HCU.
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Affiliation(s)
- Insun Park
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Helena Hůlková
- Institute of Pathology, Charles University-First Faculty of Medicine and General University Hospital, Prague, Czech Republic.,Department of Pediatrics and Adolescent Medicine, Charles University-First Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Jakub Krijt
- Department of Pediatrics and Adolescent Medicine, Charles University-First Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Viktor Kožich
- Department of Pediatrics and Adolescent Medicine, Charles University-First Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | | | - Tomas Majtan
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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22
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Manta-Vogli PD, Schulpis KH, Dotsikas Y, Loukas YL. Nutrition and medical support during pregnancy and lactation in women with inborn errors of intermediary metabolism disorders (IEMDs). J Pediatr Endocrinol Metab 2020; 33:5-20. [PMID: 31804959 DOI: 10.1515/jpem-2019-0048] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 09/20/2019] [Indexed: 12/25/2022]
Abstract
The establishment of expanded newborn screening (NBS) not only results in the early diagnosis and treatment of neonates with inborn errors of intermediary metabolism disorders (IEMDs) but also helps the affected females to reach the reproductive age under medical and dietetic support, as well as to give birth to normal infants. In this review, we aimed to focus on laboratory investigation tests, dietetic management and medical support for most known IEMD pregnant and lactating women, such as those suffering from aminoacidopathies, carbohydrate metabolic diseases and fatty acid (FAO) oxidation disorders.
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Affiliation(s)
- Penelope D Manta-Vogli
- Department of Clinical Nutrition and Dietetics, Agia Sofia Children's Hospital, Athens, Greece
| | | | - Yannis Dotsikas
- Laboratory of Pharm. Analysis, Department of Pharmacy, National and Kapodestrian University of Athens, Panepistimiopolis Zographou, GR-157 71, Athens, Greece, Phone: +30 210 7274696, Fax: +30 210 7274039
| | - Yannis L Loukas
- Laboratory of Pharm. Analysis, Department of Pharmacy, National and Kapodestrian University of Athens, Panepistimiopolis Zographou, GR-157 71, Athens, Greece, Phone: +30 210 7274224, Fax: +30 211 1826131
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23
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Lee HO, Gallego-Villar L, Grisch-Chan HM, Häberle J, Thöny B, Kruger WD. Treatment of Cystathionine β-Synthase Deficiency in Mice Using a Minicircle-Based Naked DNA Vector. Hum Gene Ther 2019; 30:1093-1100. [PMID: 31084364 PMCID: PMC6761586 DOI: 10.1089/hum.2019.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 05/04/2019] [Indexed: 12/17/2022] Open
Abstract
Cystathionine β-synthase (CBS) deficiency is a recessive inborn error of metabolism characterized by extremely elevated total homocysteine (tHcy) in the blood. Patients diagnosed with CBS deficiency have a variety of clinical problems, including dislocated lenses, osteoporosis, cognitive and behavioral issues, and a significantly increased risk of thrombosis. Current treatment strategies involve a combination of vitamin supplementation and restriction of foods containing the homocysteine precursor methionine. Here, a mouse model for CBS deficiency (Tg-I278T Cbs-/-) was used to evaluate the potential of minicircle-based naked DNA gene therapy to treat CBS deficiency. A 2.3 kb DNA-minicircle containing the liver-specific P3 promoter driving the human CBS cDNA (MC.P3-hCBS) was delivered into Tg-I278T Cbs-/- mice via a single hydrodynamic tail vein injection. Mean serum tHcy decreased from 351 μM before injection to 176 μM 7 days after injection (p = 0.0005), and remained decreased for at least 42 days. Western blot analysis reveals significant minicircle-directed CBS expression in the liver tissue. Liver CBS activity increased 34-fold (12.8 vs. 432 units; p = 0.0004) in MC.P3-hCBS-injected animals. Injection of MC.P3-hCBS in young mice, subsequently followed for 202 days, showed that the vector can ameliorate the mouse homocystinuria alopecia phenotype. The present findings show that minicircle-based gene therapy can lower tHcy in a mouse model of CBS deficiency.
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Affiliation(s)
- Hyung-Ok Lee
- Cancer Biology Program, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Lorena Gallego-Villar
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, University Medical Centre Freiburg, Freiburg, Germany
| | - Hiu Man Grisch-Chan
- Division of Metabolism and Children's Research Center, University Children's Hospital Zurich, Switzerland
| | - Johannes Häberle
- Division of Metabolism and Children's Research Center, University Children's Hospital Zurich, Switzerland
| | - Beat Thöny
- Division of Metabolism and Children's Research Center, University Children's Hospital Zurich, Switzerland
| | - Warren D. Kruger
- Cancer Biology Program, Fox Chase Cancer Center, Philadelphia, Pennsylvania
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24
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Yeoh C, Teng H, Jackson J, Hingula L, Irie T, Legler A, Levine C, Chu I, Chai C, Tollinche L. Metabolic Disorders and Anesthesia. CURRENT ANESTHESIOLOGY REPORTS 2019; 9:340-359. [PMID: 31406490 DOI: 10.1007/s40140-019-00345-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Purpose of Review Metabolic disorders encompass a group of inherited inborn errors of metabolism that are uncommonly encountered but can pose challenges when encountered during the perioperative period. Hence, it is paramount that anesthesiologists are experienced and familiar with management of these conditions. Recent Findings Hundreds of inborn errors of metabolism have already been identified, yet new metabolic disorders continue to be discovered with advancements in genomic science. Summary In our general review, we define the more common metabolic disorders encountered in perioperative medicine and discuss the perioperative anesthetic considerations and challenges associated with each disorder. The following disorders are covered in our review: disorders of carbohydrate metabolism, disorders of amino acid metabolism, disorders of branched-chain amino acid metabolism, organic acidemias, mitochondrial disorders, lysosomal storage disorders, metal metabolism disorders, and urea cycle disorders.
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Affiliation(s)
- Cindy Yeoh
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Howard Teng
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Jacob Jackson
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Lee Hingula
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Takeshi Irie
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Aron Legler
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Corrine Levine
- Department of Anesthesiology, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY, USA
| | - Iris Chu
- Department of Anesthesiology, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY, USA
| | - Casey Chai
- Department of Anesthesiology, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY, USA
| | - Luis Tollinche
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
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25
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Van Hove JLK, Freehauf CL, Ficicioglu C, Pena LDM, Moreau KL, Henthorn TK, Christians U, Jiang H, Cowan TM, Young SP, Hite M, Friederich MW, Stabler SP, Spector EB, Kronquist KE, Thomas JA, Emmett P, Harrington MJ, Pyle L, Creadon-Swindell G, Wempe MF, MacLean KN. Biomarkers of oxidative stress, inflammation, and vascular dysfunction in inherited cystathionine β-synthase deficient homocystinuria and the impact of taurine treatment in a phase 1/2 human clinical trial. J Inherit Metab Dis 2019; 42:424-437. [PMID: 30873612 DOI: 10.1002/jimd.12085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 03/11/2019] [Indexed: 11/10/2022]
Abstract
STUDY OBJECTIVE A phase 1/2 clinical trial was performed in individuals with cystathionine β synthase (CBS) deficient homocystinuria with aims to: (a) assess pharmacokinetics and safety of taurine therapy, (b) evaluate oxidative stress, inflammation, and vascular function in CBS deficiency, and (c) evaluate the impact of short-term taurine treatment. METHODS Individuals with pyridoxine-nonresponsive CBS deficiency with homocysteine >50 μM, without inflammatory disorder or on antioxidant therapy were enrolled. Biomarkers of oxidative stress and inflammation, endothelial function (brachial artery flow-mediated dilation [FMD]), and disease-related metabolites obtained at baseline were compared to normal values. While maintaining current treatment, patients were treated with 75 mg/kg taurine twice daily, and treatment response assessed after 4 hours and 4 days. RESULTS Fourteen patients (8-35 years; 8 males, 6 females) were enrolled with baseline homocysteine levels 161 ± 67 μM. The study found high-dose taurine to be safe when excluding preexisting hypertriglyceridemia. Taurine pharmacokinetics showed a rapid peak level returning to near normal levels at 12 hours, but had slow accumulation and elevated predosing levels after 4 days of treatment. Only a single parameter of oxidative stress, 2,3-dinor-8-isoprostaglandin-F2α, was elevated at baseline, with no elevated inflammatory parameters, and no change in FMD values overall. Taurine had no effect on any of these parameters. However, the effect of taurine was strongly related to pretreatment FMD values; and taurine significantly improved FMD in the subset of individuals with pretreatment FMD values <10% and in individuals with homocysteine levels >125 μM, pertinent to endothelial function. CONCLUSION Taurine improves endothelial function in CBS-deficient homocystinuria in patients with preexisting reduced function.
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Affiliation(s)
- Johan L K Van Hove
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Cynthia L Freehauf
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Can Ficicioglu
- Division of Human Genetics, The Children's Hospital Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Loren D M Pena
- Division of Medical Genetics, Department of Pediatrics, Duke University, Durham, North Carolina
| | - Kerrie L Moreau
- Department of Medicine, School of Medicine, University of Colorado, Aurora, Colorado
- Geriatric Research and Education Center, Denver Veterans Administration Medical Center, Aurora, Colorado
| | - Thomas K Henthorn
- iC42 Clinical Research and Development, Department of Anesthesiology, School of Medicine, University of Colorado, Aurora, Colorado
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
| | - Uwe Christians
- iC42 Clinical Research and Development, Department of Anesthesiology, School of Medicine, University of Colorado, Aurora, Colorado
| | - Hua Jiang
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Tina M Cowan
- Department of Pathology, Stanford University, Stanford, California
| | - Sarah P Young
- Division of Medical Genetics, Department of Pediatrics, Duke University, Durham, North Carolina
| | - Michelle Hite
- Research Institute, Children's Hospital Colorado, Aurora, Colorado
| | - Marisa W Friederich
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Sally P Stabler
- Department of Medicine, School of Medicine, University of Colorado, Aurora, Colorado
| | - Elaine B Spector
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Kathryn E Kronquist
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Janet A Thomas
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Peggy Emmett
- CTRC Core Laboratory, Children's Hospital Colorado, Aurora, Colorado
| | - Mary J Harrington
- CTRC Core Laboratory, Children's Hospital Colorado, Aurora, Colorado
| | - Laura Pyle
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, Colorado
| | | | - Michael F Wempe
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
| | - Kenneth N MacLean
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
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26
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Jakubowski H. Homocysteine Modification in Protein Structure/Function and Human Disease. Physiol Rev 2019; 99:555-604. [PMID: 30427275 DOI: 10.1152/physrev.00003.2018] [Citation(s) in RCA: 154] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Epidemiological studies established that elevated homocysteine, an important intermediate in folate, vitamin B12, and one carbon metabolism, is associated with poor health, including heart and brain diseases. Earlier studies show that patients with severe hyperhomocysteinemia, first identified in the 1960s, exhibit neurological and cardiovascular abnormalities and premature death due to vascular complications. Although homocysteine is considered to be a nonprotein amino acid, studies over the past 2 decades have led to discoveries of protein-related homocysteine metabolism and mechanisms by which homocysteine can become a component of proteins. Homocysteine-containing proteins lose their biological function and acquire cytotoxic, proinflammatory, proatherothrombotic, and proneuropathic properties, which can account for the various disease phenotypes associated with hyperhomocysteinemia. This review describes mechanisms by which hyperhomocysteinemia affects cellular proteostasis, provides a comprehensive account of the biological chemistry of homocysteine-containing proteins, and discusses pathophysiological consequences and clinical implications of their formation.
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Affiliation(s)
- Hieronim Jakubowski
- Department of Microbiology, Biochemistry and Molecular Genetics, Rutgers-New Jersey Medical School, International Center for Public Health , Newark, New Jersey ; and Department of Biochemistry and Biotechnology, Poznań University of Life Sciences , Poznań , Poland
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27
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Hoss GRW, Poloni S, Blom HJ, Schwartz IVD. Three Main Causes of Homocystinuria: CBS, cblC and MTHFR Deficiency. What do they Have in Common? JOURNAL OF INBORN ERRORS OF METABOLISM AND SCREENING 2019. [DOI: 10.1590/2326-4594-jiems-2019-0007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
| | - Soraia Poloni
- Universidade Federal do Rio Grande do Sul, Brazil; Hospital de Clínicas de Porto Alegre, Brazil
| | - Henk J Blom
- University Medical Centre Amsterdam, Netherlands
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28
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Poloni S, Hoss GW, Sperb-Ludwig F, Borsatto T, Doriqui MJR, Leão EK, Boa-Sorte N, Lourenço CM, Kim CA, de Souza CFM, Rocha H, Ribeiro M, Steiner CE, Moreno CA, Bernardi P, Valadares E, Artigalas O, Carvalho G, Wanderley HYC, D’Almeida V, Santana-da-Silva LC, Blom HJ, Schwartz IVD. Diagnosis and Management of Classical Homocystinuria in Brazil. JOURNAL OF INBORN ERRORS OF METABOLISM AND SCREENING 2018. [DOI: 10.1177/2326409818788900] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Soraia Poloni
- Post-Graduation Program in Medical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Laboratory of Basic Research and Advanced Investigations in Neurosciences (BRAIN), Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Giovana W. Hoss
- Laboratory of Basic Research and Advanced Investigations in Neurosciences (BRAIN), Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Post-Graduation Program in Genetics and Molecular Biology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Fernanda Sperb-Ludwig
- Laboratory of Basic Research and Advanced Investigations in Neurosciences (BRAIN), Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Post-Graduation Program in Genetics and Molecular Biology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Taciane Borsatto
- Laboratory of Basic Research and Advanced Investigations in Neurosciences (BRAIN), Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Post-Graduation Program in Genetics and Molecular Biology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Emília K.E.A Leão
- Complexo Hospitalar Professor Edgard Santos, Salvador, Brazil
- Universidade do Estado da Bahia, Salvador, Brazil
| | - Ney Boa-Sorte
- Complexo Hospitalar Professor Edgard Santos, Salvador, Brazil
- Universidade do Estado da Bahia, Salvador, Brazil
| | - Charles M. Lourenço
- Hospital das Clínicas de Ribeirão Preto, Ribeirão Preto, Brazil
- Centro Universitário Estácio de Ribeirão Preto, Ribeirão Preto, Brazil
| | | | | | - Helio Rocha
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcia Ribeiro
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | | | | | - Osvaldo Artigalas
- Hospital da Criança Conceição, GHC, Porto Alegre, Brazil
- Hospital Materno-Infantil Presidente Vargas, Porto Alegre, Brazil
| | | | | | - Vânia D’Almeida
- Department of Psychobiology, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Henk J. Blom
- Laboratory for Clinical Biochemistry and Metabolism, University Medical Center, Freiburg, Germany
| | - Ida V. D. Schwartz
- Post-Graduation Program in Medical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Laboratory of Basic Research and Advanced Investigations in Neurosciences (BRAIN), Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Post-Graduation Program in Genetics and Molecular Biology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Medical Genetics Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
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29
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Ospina-Romero M, Cannegieter SC, den Heijer M, Doggen CJM, Rosendaal FR, Lijfering WM. Hyperhomocysteinemia and Risk of First Venous Thrombosis: The Influence of (Unmeasured) Confounding Factors. Am J Epidemiol 2018; 187:1392-1400. [PMID: 29370361 DOI: 10.1093/aje/kwy004] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 01/04/2018] [Indexed: 11/13/2022] Open
Abstract
Meta-analyses have reported a 2- to 3-fold increased risk of venous thrombosis (VT) in individuals with hyperhomocysteinemia. However, confounding factors were generally not considered. In contrast, randomized trials of homocysteine-lowering therapy and VT risk have been negative. We investigated whether hyperhomocysteinemia was associated with VT in the Multiple Environmental and Genetic Assessment of Risk Factors for Venous Thrombosis (MEGA) case-control study (1999-2004) from the Netherlands (1,689 cases and 1,726 controls), taking into account measured and unmeasured confounders. We compared patients with population controls to estimate odds ratios using unconditional logistic regression and adjusted for various potential confounders. We matched patients to their partners to additionally adjust for unmeasured confounders (e.g., lifestyle factors) using conditional logistic regression. We found that elevated homocysteine concentrations were not associated with an increased risk for VT when comparing patients with population controls, either as a continuous variable (odds ratio = 1.00, 95% confidence interval: 0.99, 1.01), in terms of 0.7-mg/L increase (odds ratio = 0.99, 95% confidence interval: 0.93, 1.05), or within different homocysteine categories. We obtained similar results when patients were compared with their partners. Stratification by sex, deep vein thrombosis, pulmonary embolism, provoked VT, and unprovoked VT also provided no evidence of an association. In conclusion, after extensive adjustments for confounding, hyperhomocysteinemia was not associated with an increased risk of venous thrombosis in this study.
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Affiliation(s)
- Monica Ospina-Romero
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Martin den Heijer
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Internal Medicine, VU Medical Center, Amsterdam, the Netherlands
| | - Carine J M Doggen
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Health Technology and Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, the Netherlands
| | - Frits R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Willem M Lijfering
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, the Netherlands
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30
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Maddock J, Ambrosini GL, Griffin JL, West JA, Wong A, Hardy R, Ray S. A dietary pattern derived using B-vitamins and its relationship with vascular markers over the life course. Clin Nutr 2018; 38:1464-1473. [PMID: 30005901 PMCID: PMC6546956 DOI: 10.1016/j.clnu.2018.06.969] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 03/20/2018] [Accepted: 06/18/2018] [Indexed: 02/04/2023]
Abstract
Background Diet may influence vascular function through elevated homocysteine (Hcy) concentrations. However the relationship between dietary patterns (DP), characterised by Hcy and its associated nutrients is unknown. Objective To identify a DP characterised by plasma Hcy, dietary folate and dietary vitamin B12, and examine its associations with two markers of vascular function: carotid intima-media thickness (cIMT) and pulse wave velocity (PWV). Methods 1562 participants of the MRC National Survey of Health and Development (NSHD), a British birth cohort, with dietary data measured at least once between 36 and 60–64 years, and cIMT or PWV measured at 60–64 years were included. DPs were derived using reduced rank regression with three intermediate variables: 1) plasma Hcy (μmol/L) 2) folate intake (μg/1000 kcal) 3) vitamin B12 intake (μg/1000 kcal). Multiple regression models assessed associations between the derived DP z-scores and vascular function adjusting for dietary misreporting, socioeconomic position, BMI, smoking, physical activity and diabetes. Results A DP explaining the highest amount of shared variation (4.5%) in plasma Hcy, dietary folate and dietary vitamin B12 highly correlated with folate (r = 0.96), moderately correlated with vitamin B12 (r = 0.27), and weakly correlated with Hcy (r = 0.10). This “high B-vitamin” DP (including folate) was characterised by high intakes of vegetables, fruit and low fibre breakfast cereal, and low intakes of processed meat, white bread, sugar and preserves. No associations were observed between DP z-scores and vascular function at any time point following adjustment for covariates. Conclusion This study explored a specific hypothesised pathway linking diet to vascular function. Although we found no consistent evidence for an association between a high B-vitamin DP and vascular function, we did observe an association with CRP and triglycerides in secondary analyses. Further analyses using strongly correlated and biologically relevant intermediate variables are required to refine investigations into diet and CVD in longitudinal cohort data.
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Affiliation(s)
- Jane Maddock
- MRC Lifelong Health & Ageing at UCL, 33 Bedford Place, London WC1 B5JU, United Kingdom; MRC Elsie Widdowson Laboratory, Cambridge CB1 9NL, United Kingdom; NNEdPro Global Centre for Nutrition and Health (Affiliated with: Cambridge University Health Partners, Wolfson College Cambridge and the British Dietetic Association), St John's Innovation Centre, Cowley Road, Cambridge CB4 0WS, United Kingdom.
| | - Gina L Ambrosini
- MRC Elsie Widdowson Laboratory, Cambridge CB1 9NL, United Kingdom; School of Population and Global Health, The University of Western Australia, 35 Stirling Highway, Crawley 6009, Perth, Western Australia, Australia
| | - Julian L Griffin
- Department of Biochemistry, Tennis Court Road, University of Cambridge, Cambridge, CB2 1GA, United Kingdom
| | - James A West
- Department of Biochemistry, Tennis Court Road, University of Cambridge, Cambridge, CB2 1GA, United Kingdom
| | - Andrew Wong
- MRC Lifelong Health & Ageing at UCL, 33 Bedford Place, London WC1 B5JU, United Kingdom
| | - Rebecca Hardy
- MRC Lifelong Health & Ageing at UCL, 33 Bedford Place, London WC1 B5JU, United Kingdom
| | - Sumantra Ray
- MRC Elsie Widdowson Laboratory, Cambridge CB1 9NL, United Kingdom; NNEdPro Global Centre for Nutrition and Health (Affiliated with: Cambridge University Health Partners, Wolfson College Cambridge and the British Dietetic Association), St John's Innovation Centre, Cowley Road, Cambridge CB4 0WS, United Kingdom.
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31
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Johnson M, Murphy E, Raheem A, Ralph D. Poorly Controlled Homocystinuria: A Rare Cause of Ischemic Priapism? Sex Med 2018; 6:171-173. [PMID: 29463473 PMCID: PMC5960025 DOI: 10.1016/j.esxm.2017.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 12/08/2017] [Accepted: 12/20/2017] [Indexed: 11/25/2022] Open
Abstract
We report on the 1st case of ischemic priapism secondary to poorly controlled homocystinuria. Homocystinuria is a rare, autosomal recessive, inherited disorder of metabolism that is caused by a deficiency of cystathionine synthase, leading to marked hyperhomocysteinemia. Arterial and/or venous thromboemboli are a major cause of mortality and morbidity in patients with homocystinuria. Untreated patients have a 50% chance of having a vascular event by 30 years of age. Increased homocysteine levels have been reported to upregulate prothrombotic factors and downregulate antithrombotic factors; in particular, increased homocystinuria has been found to downregulate nitric oxide (NO). Mice that are deficient in NO synthase in the cavernosal smooth muscles have a higher incidence of priapism. Decrease in NO synthase causes downregulation of cyclic guanosine monophosphate, phosphodiesterase type 5A, and Rho A/Rho-kinase. Because persistently increased homocysteine also downregulates NO, a similar mechanism could be proposed for priapism secondary to homocystinuria. In patients presenting with priapism, specific features of homocystinuria should be sought; in selected patients, screening with plasma total homocysteine might be appropriate. Ischemic priapism secondary to homocystinuria appears to respond well to the standard treatment options of aspiration, intracavernosal injection with phenylephrine, and, if required, a shunting procedure. Johnson M, Murphy E, Raheem A, Ralph D. Poorly Controlled Homocystinuria: A Rare Cause of Ischemic Priapism? Sex Med 2018;6:171–173.
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32
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Lorenzini M, Guha N, Davison JE, Pitcher A, Pandya B, Kemp H, Lachmann R, Elliott PM, Murphy E. Isolated aortic root dilation in homocystinuria. J Inherit Metab Dis 2018; 41:109-115. [PMID: 28980096 PMCID: PMC5786652 DOI: 10.1007/s10545-017-0094-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 08/17/2017] [Accepted: 09/15/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND Vascular complications in homocystinuria have been known for many years, but there have been no reports to date on involvement of the ascending aorta. METHODS We conducted a cross-sectional study of patients with homocystinuria, known to a single metabolic centre, and evaluated in 2016 with a transthoracic echocardiogram. Aortic root dilation was defined as Z-score ≥ 2.0 SD, and graded mild (Z-score 2.0-3.0), moderate (Z-score 3.01-4.0) and severe (Z-score > 4.0). RESULTS The study population included 34 patients, median age of 44.3 years (IQR 33.3-52.2), 50% males, 69% diagnosed aged <18 years and 29% pyridoxine-responsive. Eight (24%) had a history of hypertension. Seven patients (21%) were found to have a dilation of the aortic root, mild in two cases (6%), moderate in four (12%) and severe in one (3%). None had dilation of the ascending aorta. Significant aortic regurgitation, secondary to moderate aortic root dilation, was documented in two patients. A single patient had significant mitral regurgitation due to prolapse of both valve leaflets, as well as mild aortic root dilation. Comparing patients with a dilation of the aortic root to those without, there were no significant clinical, laboratory or echocardiographic differences, with the only exception being that the diameter of the ascending aorta was larger in the group with a dilated aortic root, albeit within normal limits. CONCLUSIONS A subset of patients with homocystinuria have isolated dilation of the aortic root similar to that observed in Marfan syndrome.
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Affiliation(s)
- Massimiliano Lorenzini
- University College London Institute for Cardiovascular Science and Barts Heart Centre, St. Bartholomew's Hospital, London, UK
- Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Nishan Guha
- Department of Clinical Biochemistry, John Radcliffe Hospital and Nuffield Division of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - James E Davison
- Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Alex Pitcher
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Bejal Pandya
- Adult Congenital Heart Disease Department, Barts Heart Centre, St. Bartholomew's Hospital, London, UK
| | - Helena Kemp
- Department of Clinical Biochemistry, North Bristol NHS Trust, Bristol, UK
| | - Robin Lachmann
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Perry M Elliott
- University College London Institute for Cardiovascular Science and Barts Heart Centre, St. Bartholomew's Hospital, London, UK
| | - Elaine Murphy
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK.
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33
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Majtan T, Jones W, Krijt J, Park I, Kruger WD, Kožich V, Bassnett S, Bublil EM, Kraus JP. Enzyme Replacement Therapy Ameliorates Multiple Symptoms of Murine Homocystinuria. Mol Ther 2017; 26:834-844. [PMID: 29398487 DOI: 10.1016/j.ymthe.2017.12.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 12/12/2017] [Accepted: 12/14/2017] [Indexed: 01/21/2023] Open
Abstract
Classical homocystinuria (HCU) is the most common inherited disorder of sulfur amino acid metabolism caused by deficiency in cystathionine beta-synthase (CBS) activity and characterized by severe elevation of homocysteine in blood and tissues. Treatment with dietary methionine restriction is not optimal, and poor compliance leads to serious complications. We developed an enzyme replacement therapy (ERT) and studied its efficacy in a severe form of HCU in mouse (the I278T model). Treatment was initiated before or after the onset of clinical symptoms in an effort to prevent or reverse the phenotype. ERT substantially reduced and sustained plasma homocysteine concentration at around 100 μM and normalized plasma cysteine for up to 9 months of treatment. Biochemical balance was also restored in the liver, kidney, and brain. Furthermore, ERT corrected liver glucose and lipid metabolism. The treatment prevented or reversed facial alopecia, fragile and lean phenotype, and low bone mass. In addition, structurally defective ciliary zonules in the eyes of I278T mice contained low density and/or broken fibers, while administration of ERT from birth partially rescued the ocular phenotype. In conclusion, ERT maintained an improved metabolic pattern and ameliorated many of the clinical complications in the I278T mouse model of HCU.
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Affiliation(s)
- Tomas Majtan
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045, USA.
| | - Wendell Jones
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Jakub Krijt
- Department of Pediatrics and Adolescent Medicine, Charles University-First Faculty of Medicine and General University Hospital in Prague, Prague 12808, Czech Republic
| | - Insun Park
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Warren D Kruger
- Cancer Biology Program, Fox Chase Cancer Center, Philadelphia, PA 19111, USA
| | - Viktor Kožich
- Department of Pediatrics and Adolescent Medicine, Charles University-First Faculty of Medicine and General University Hospital in Prague, Prague 12808, Czech Republic
| | - Steven Bassnett
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Erez M Bublil
- Orphan Technologies, Ltd., Rapperswil 8640, Switzerland
| | - Jan P Kraus
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045, USA.
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34
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Majtan T, Park I, Bublil EM, Kraus JP. Enzyme replacement therapy prevents loss of bone and fat mass in murine homocystinuria. Hum Mutat 2017; 39:210-218. [PMID: 29044829 DOI: 10.1002/humu.23360] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 10/03/2017] [Accepted: 10/11/2017] [Indexed: 01/04/2023]
Abstract
Skeletal and connective tissue defects are the most striking symptoms in patients suffering from classical homocystinuria (HCU). Here, we determined body composition and bone mass in three mouse models of HCU and assessed whether a long-term administration of enzyme replacement therapy (ERT) corrected the phenotype. The mouse models of HCU were analyzed using dual-energy X-ray absorptiometry and the data were complemented by plasma biochemical profiles. Both the mouse model lacking CBS (KO) and the one expressing human CBS mutant transgene on a mouse CBS null background (I278T) showed marked bone loss and decreased weight mostly due to a lower fat content compared with negative controls. In contrast, the HO mouse expressing the human CBS WT transgene on a mouse CBS null background showed no such phenotype despite similar plasma biochemical profile to the KO and I278T mice. More importantly, administration of ERT rescued bone mass and changes in body composition in the KO mice treated since birth and reversed bone loss and improved fat content in the I278T mice injected after the development of clinical symptoms. Our study suggests that ERT for HCU may represent an effective way of preventing the skeletal problems in patients without a restricted dietary regime.
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Affiliation(s)
- Tomas Majtan
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Insun Park
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | | | - Jan P Kraus
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
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35
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Morris AAM, Kožich V, Santra S, Andria G, Ben-Omran TIM, Chakrapani AB, Crushell E, Henderson MJ, Hochuli M, Huemer M, Janssen MCH, Maillot F, Mayne PD, McNulty J, Morrison TM, Ogier H, O'Sullivan S, Pavlíková M, de Almeida IT, Terry A, Yap S, Blom HJ, Chapman KA. Guidelines for the diagnosis and management of cystathionine beta-synthase deficiency. J Inherit Metab Dis 2017; 40:49-74. [PMID: 27778219 PMCID: PMC5203861 DOI: 10.1007/s10545-016-9979-0] [Citation(s) in RCA: 191] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 08/11/2016] [Accepted: 09/12/2016] [Indexed: 12/17/2022]
Abstract
Cystathionine beta-synthase (CBS) deficiency is a rare inherited disorder in the methionine catabolic pathway, in which the impaired synthesis of cystathionine leads to accumulation of homocysteine. Patients can present to many different specialists and diagnosis is often delayed. Severely affected patients usually present in childhood with ectopia lentis, learning difficulties and skeletal abnormalities. These patients generally require treatment with a low-methionine diet and/or betaine. In contrast, mildly affected patients are likely to present as adults with thromboembolism and to respond to treatment with pyridoxine. In this article, we present recommendations for the diagnosis and management of CBS deficiency, based on a systematic review of the literature. Unfortunately, the quality of the evidence is poor, as it often is for rare diseases. We strongly recommend measuring the plasma total homocysteine concentrations in any patient whose clinical features suggest the diagnosis. Our recommendations may help to standardise testing for pyridoxine responsiveness. Current evidence suggests that patients are unlikely to develop complications if the plasma total homocysteine concentration is maintained below 120 μmol/L. Nevertheless, we recommend keeping the concentration below 100 μmol/L because levels fluctuate and the complications associated with high levels are so serious.
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Affiliation(s)
- Andrew A M Morris
- Institute of Human Development, University of Manchester, Manchester, UK.
- Willink Unit, Manchester Centre for Genomic Medicine, Central Manchester University Hospitals, St Mary's Hospital, Oxford Road, Manchester, M13 9WL, UK.
| | - Viktor Kožich
- Institute of Inherited Metabolic Disorders, Charles University in Prague-First Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
| | - Saikat Santra
- Clinical IMD, Birmingham Children's Hospital, Birmingham, UK
| | - Generoso Andria
- Department of translational medicine, Federico II University, Naples, Italy
| | | | | | - Ellen Crushell
- National Centre for Inherited Metabolic Disorders, Temple Street Children's University Hospital, Dublin, Ireland
| | - Mick J Henderson
- Willink Unit, Manchester Centre for Genomic Medicine, Central Manchester University Hospitals, St Mary's Hospital, Oxford Road, Manchester, M13 9WL, UK
- Biochemical Genetics, St James' University Hospital, Leeds, UK
| | - Michel Hochuli
- Division of Endocrinology, Diabetes and Clinical Nutrition, University Hospital Zürich, Zurich, Switzerland
| | - Martina Huemer
- Division of Metabolism and Children's Research Center, University Children's Hospital Zürich, Zurich, Switzerland
- Rare Disease Initiative Zürich, University of Zürich, Zurich, Switzerland
- Dept. of Paediatrics, Landeskrankenhaus Bregenz, Bregenz, Austria
| | - Miriam C H Janssen
- Department of Internal medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Philip D Mayne
- Newborn Bloodspot Screening Laboratory, Temple Street Children's University Hospital, Dublin, Ireland
| | - Jenny McNulty
- National Centre for Inherited Metabolic Disorders, Temple Street Children's University Hospital, Dublin, Ireland
| | | | - Helene Ogier
- Service de Neurologie Pédiatrique et des Maladies Métaboliques, Hôpital Robert Debré, Paris, France
| | | | - Markéta Pavlíková
- Institute of Inherited Metabolic Disorders, Charles University in Prague-First Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
| | | | - Allyson Terry
- Institute of Human Development, University of Manchester, Manchester, UK
- Dietetic Department, Alder Hey Hospital, Liverpool, UK
| | - Sufin Yap
- Dept of Inherited Metabolic Diseases, Sheffield Children's Hospital, Sheffield, UK
| | - Henk J Blom
- Laboratory of Clinical Biochemistry and Metabolism, Department of General Pediatrics, Adolescent Medicine and Neonatology, University Medical Centre Freiburg, Freiburg im Breisgau, Germany
| | - Kimberly A Chapman
- Division of Genetic and Metabolism, Children's National Health System, Washington, DC, USA
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36
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Goldstein A, Vockley J. Clinical trials examining treatments for inborn errors of amino acid metabolism. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2017.1275565] [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: 12/24/2022]
Affiliation(s)
- Amy Goldstein
- Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jerry Vockley
- Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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37
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Homocysteine and disease: Causal associations or epiphenomenons? Mol Aspects Med 2016; 53:36-42. [PMID: 27876556 DOI: 10.1016/j.mam.2016.11.003] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 11/18/2016] [Indexed: 01/08/2023]
Abstract
Nutritional and genetic deficiencies of folate and vitamin B12 lead to elevation of cellular homocysteine (Hcy), which translates in increased plasma Hcy. The sources and role of elevated plasma Hcy in pathology continues to be a subject of intense scientific debate. Whether a cause, mediator or marker, little is known about the molecular mechanisms and interactions of Hcy with cellular processes that lead to disease. The use of folic acid reduces the incidence of neural tube defects, but the effect of Hcy-lowering interventions with folic acid in cardiovascular disease and cognitive impairment remains controversial. The fact that levels of Hcy in plasma do not always reflect cellular status of this amino acid may account for the substantial gaps that exist between epidemiological, intervention and basic research studies. Understanding whether plasma Hcy is a mechanistic player or an epiphenomenon in pathogenesis requires further investigation, and this research is essential to improve the assessment and potential treatment of hyperhomocysteinemias.
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38
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Treatable high homocysteine alone or in concert with five other thrombophilias in 1014 patients with thrombotic events. Blood Coagul Fibrinolysis 2016; 26:736-42. [PMID: 25699608 DOI: 10.1097/mbc.0000000000000276] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In 1014 patients with thrombotic events, we determined how often treatable high serum homocysteine alone, or in concert with five other thrombophilias, was associated with thrombotic events. We studied 1014 outpatients sequentially referred for evaluation of thrombotic events, all having six measures of thrombophilia--three PCR (methylenetetrahydrofolate reductase C677T-A1298C, factor V Leiden G506A, prothrombin G20210A), and three serologic (factors VIII, XI, homocysteine). Of the 1014 patients, 198 (20%) had atherothrombosis, 199 (20%) ocular vascular thrombosis, 211 (21%) osteonecrosis, 180 (18%) pseudotumor cerebri, and 123 (12%) recurrent miscarriage. In 434 of 1014 (43%) patients, all six thrombophilic measures were normal. High homocysteine, present in 126 of 1014 patients (12.4%), was the sole thrombophilia in 50 (5%), accompanied only by methylenetetrahydrofolate reductase homozygosity-compound heterozygosity in 22 (2.2%), and accompanied by other thrombophilias in 54 (5%). Patients were more likely than 110 healthy controls to have high homocysteine (12 vs. 5%; P = 0.02) and high factor VIII (21 vs. 7%; P = 0.0003). On treatment for a median of 18 months with L-methyl folate (5 mg), vitamin B6 (100 mg), and vitamin B12 (2 mg/day), in 74 homocysteinemic patients, median homocysteine fell from 15.6 to 10.0 μmol/l (P < 0.0001), and in 56 (76%), homocysteine fell to normal on treatment. When homocysteinemia was the sole thrombophilia, normalization of homocysteine was accompanied by freedom from new thrombotic events in 38 of 41 patients (93%). In evaluation of 1014 patients with thrombotic events, 126 (12%) had treatable high serum homocysteine, and in 50 (5%), high homocysteine was the sole treatable thrombophilia.
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Mundada V, Krishnakumar D, Chitre M, Das T. Answers to Epilogue questions. Arch Dis Child Educ Pract Ed 2016; 101:165. [PMID: 27194774 DOI: 10.1136/archdischild-2014-306744a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 05/10/2015] [Indexed: 11/03/2022]
Affiliation(s)
- Vivek Mundada
- Department of Paediatric Neurology, Addenbrooke's Hospital, Cambridge, UK
| | - Deepa Krishnakumar
- Department of Paediatric Neurology, Addenbrooke's Hospital, Cambridge, UK
| | - Manali Chitre
- Department of Paediatric Neurology, Addenbrooke's Hospital, Cambridge, UK
| | - Tilak Das
- Department of Radiology, Addenbrooke's Hospital, Cambridge, UK
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Bublil EM, Majtan T, Park I, Carrillo RS, Hůlková H, Krijt J, Kožich V, Kraus JP. Enzyme replacement with PEGylated cystathionine β-synthase ameliorates homocystinuria in murine model. J Clin Invest 2016; 126:2372-84. [PMID: 27183385 DOI: 10.1172/jci85396] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 03/22/2016] [Indexed: 01/16/2023] Open
Abstract
Homocystinuria, which typically results from cystathionine β-synthase (CBS) deficiency, is the most common defect of sulfur amino acid metabolism. CBS condenses homocysteine and serine to cystathionine that is then converted to cysteine. Individuals with homocystinuria have markedly elevated plasma levels of homocysteine and methionine and reduced concentrations of cystathionine and cysteine. Clinical disease manifestations include thromboembolism and neuropsychiatric, ocular, and skeletal complications. Here, we have shown that administration of PEGylated CBS into the circulation of homocystinuria model mice alters the extra- and intracellular equilibrium of sulfur amino acids, resulting in a decrease of approximately 75% in plasma total homocysteine (tHcy) and normalization of cysteine concentrations. Moreover, the decrease in homocysteine and the normalization of cysteine in PEGylated CBS-treated model mice were accompanied by improvement of histopathological liver symptoms and increased survival. Together, these data suggest that CBS enzyme replacement therapy (ERT) is a promising approach for the treatment of homocystinuria and that ERT for metabolic diseases may not necessitate introduction of the deficient enzyme into its natural intracellular compartment.
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Sørensen JT, Gaustadnes M, Stabler SP, Allen RH, Mudd SH, Hvas AM. Molecular and biochemical investigations of patients with intermediate or severe hyperhomocysteinemia. Mol Genet Metab 2016; 117:344-50. [PMID: 26750749 DOI: 10.1016/j.ymgme.2015.12.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Revised: 12/22/2015] [Accepted: 12/22/2015] [Indexed: 10/22/2022]
Abstract
A discrepancy has been identified between numbers of expected and identified patients with homocystinuria due to cystathionine beta-synthase (CBS) deficiency. Patients homozygous for the frequent c.833T>C (p.I278T) are most often responsive to vitamin B6, and can present with a total-homocysteine (tHcy) <100 μM on a normal diet. In Denmark, patients with tHcy <100 μM are not routinely sequenced for CBS(2) mutations. This study investigated the prevalence of CBS mutations and the common methylenetetrahydrofolate reductase (MTHFR) c.677C>T polymorphism in patients with tHcy ≥ 50 μM and the association with clinical manifestations. We studied a cohort of patients with intermediate and severe hyperhomocysteinemia (tHcy ≥ 50 μM) determined between 1996 and 2011. Among the 413 eligible patients, 184 (45%) patients agreed to participate in the present follow-up study. A MTHFR(3)c.677TT genotype was found in 49% of the patients. Eight patients were found to have mutations in CBS(2). Of those, two were homozygous for c.833T>C (p.I278T), and four were compound heterozygous for c.833T>C. One c.833T>C (p.I278T) compound heterozygote was identified by lowering the threshold for sequencing from tHcy at 100 μM to 50 μM. The most prominent clinical presentation among patients with a CBS(2) mutation was thrombosis presenting at a median age of 25 years. In case of arterial or venous thrombosis without any explanation in individuals below 40 years, tHcy should be part of the thrombophilia screening. When tHcy is between 50 and 100 μM genotyping for the MTHFR(3) c.677TT is relevant, and when tHcy >100 μM CBS should be genotyped.
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Affiliation(s)
- Jannie Tanderup Sørensen
- Centre for Haemophilia and Thrombosis, Department of Clinical Biochemistry Aarhus University Hospital, Denmark
| | - Mette Gaustadnes
- Department of Molecular Medicine, Aarhus University Hospital, Denmark
| | - Sally P Stabler
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert H Allen
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - S Harvey Mudd
- Laboratory of Molecular Biology, National Institute of Mental Health, NIH, Bethesda, USA
| | - Anne-Mette Hvas
- Centre for Haemophilia and Thrombosis, Department of Clinical Biochemistry Aarhus University Hospital, Denmark.
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Santilli F, Davì G, Patrono C. Homocysteine, methylenetetrahydrofolate reductase, folate status and atherothrombosis: A mechanistic and clinical perspective. Vascul Pharmacol 2016; 78:1-9. [DOI: 10.1016/j.vph.2015.06.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Revised: 06/17/2015] [Accepted: 06/20/2015] [Indexed: 10/23/2022]
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Gupta S, Wang L, Kruger WD. Betaine supplementation is less effective than methionine restriction in correcting phenotypes of CBS deficient mice. J Inherit Metab Dis 2016; 39:39-46. [PMID: 26231230 PMCID: PMC4784539 DOI: 10.1007/s10545-015-9883-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 07/03/2015] [Accepted: 07/07/2015] [Indexed: 10/23/2022]
Abstract
Cystathionine beta synthase (CBS) deficiency is a recessive inborn error of metabolism characterized by elevated serum total homocysteine (tHcy). Betaine supplementation, which can lower tHcy by stimulating homocysteine remethylation to methionine, is often given to CBS deficient patients in combination with other treatments such as methionine restriction and supplemental B-vitamins. However, the effectiveness of betaine supplementation by itself in the treatment of CBS deficiency has not been well explored. Here, we have examined the effect of a betaine supplemented diet on the Tg-I278T Cbs (-/-) mouse model of CBS deficiency and compared its effectiveness to our previously published data using a methionine restricted diet. Tg-I278T Cbs (-/-) mice on betaine, from the time of weaning until for 240 days of age, had a 40 % decrease in mean tHcy level and a 137 % increase in serum methionine levels. Betaine-treated Tg-I278T Cbs (-/-) mice also exhibited increased levels of betaine-dependent homocysteine methyl transferase (BHMT), increased levels of the lipogenic enzyme stearoyl-coenzyme A desaturase (SCD-1), and increased lipid droplet accumulation in the liver. Betaine supplementation largely reversed the hair loss phenotype in Tg-I278T Cbs (-/-) animals, but was far less effective than methionine restriction in reversing the weight-loss, fat-loss, and osteoporosis phenotypes. Surprisingly, betaine supplementation had several negative effects in control Tg-I278T Cbs (+/-) mice including decreased weight gain, lean mass, and bone mineral density. Our findings indicate that while betaine supplementation does have some beneficial effects, it is not as effective as methionine restriction for reversing the phenotypes associated with severe CBS deficiency in mice.
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Affiliation(s)
- Sapna Gupta
- Cancer Biology Program, Fox Chase Cancer Center, Philadelphia, PA, 19111, USA
| | - Liqun Wang
- Cancer Biology Program, Fox Chase Cancer Center, Philadelphia, PA, 19111, USA
| | - Warren D Kruger
- Cancer Biology Program, Fox Chase Cancer Center, Philadelphia, PA, 19111, USA.
- Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA, 19111, USA.
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Kasner SE, Cucchiara BL. Treatment of “Other” Stroke Etiologies. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00056-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Roriz M, Arnoux J, Bigot A, Lioger B, Maillot F. Luxation du cristallin chez le sujet de 30ans : pensez à l’homocystinurie ! Rev Med Interne 2015. [DOI: 10.1016/j.revmed.2015.10.185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kruger WD, Gupta S. The effect of dietary modulation of sulfur amino acids on cystathionine β synthase-deficient mice. Ann N Y Acad Sci 2015; 1363:80-90. [PMID: 26599618 DOI: 10.1111/nyas.12967] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Cystathionine β synthase (CBS) is a key enzyme in the methionine and cysteine metabolic pathway, acting as a metabolic gatekeeper to regulate the flow of fixed sulfur from methionine to cysteine. Mutations in the CBS gene cause clinical CBS deficiency, a disease characterized by elevated plasma total homocysteine (tHcy) and methionine and decreased plasma cysteine. The treatment goal for CBS-deficient patients is to normalize the metabolic values of these three metabolites using a combination of vitamin therapy and dietary manipulation. To better understand the effectiveness of nutritional treatment strategies, we have performed a series of long-term dietary manipulation studies using our previously developed Tg-I278T Cbs(-/-) mouse model of CBS deficiency and sibling Tg-I278T Cbs(+/-) controls. Tg-I278T Cbs(-/-) mice have undetectable levels of CBS activity, extremely elevated plasma tHcy, modestly elevated plasma methionine, and low plasma cysteine. They exhibit several easily assayable phenotypes, including osteoporosis, loss of fat mass, reduced life span, and facial alopecia. The diets used in these studies differed in the amounts of sulfur amino acids or sulfur amino acid precursors. In this review, we will discuss our findings and their relevance to CBS deficiency and the concept of gene-diet interaction.
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Affiliation(s)
- Warren D Kruger
- Cancer Biology Program, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Sapna Gupta
- Cancer Biology Program, Fox Chase Cancer Center, Philadelphia, Pennsylvania
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Huemer M, Kožich V, Rinaldo P, Baumgartner MR, Merinero B, Pasquini E, Ribes A, Blom HJ. Newborn screening for homocystinurias and methylation disorders: systematic review and proposed guidelines. J Inherit Metab Dis 2015; 38:1007-19. [PMID: 25762406 PMCID: PMC4626539 DOI: 10.1007/s10545-015-9830-z] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 02/12/2015] [Accepted: 02/23/2015] [Indexed: 01/22/2023]
Abstract
Newborn screening (NBS) is justified if early intervention is effective in a disorder generally not detected early in life on a clinical basis, and if sensitive and specific biochemical markers exist. Experience with NBS for homocystinurias and methylation disorders is limited. However, there is robust evidence for the success of early treatment with diet, betaine and/or pyridoxine for CBS deficiency and good evidence for the success of early betaine treatment in severe MTHFR deficiency. These conditions can be screened in dried blood spots by determining methionine (Met), methionine-to-phenylanine (Met/Phe) ratio, and total homocysteine (tHcy) as a second tier marker. Therefore, we recommend NBS for cystathionine beta-synthase and severe MTHFR deficiency. Weaker evidence is available for the disorders of intracellular cobalamin metabolism. Early treatment is clearly of advantage for patients with the late-onset cblC defect. In the early-onset type, survival and non-neurological symptoms improve but the effect on neurocognitive development is uncertain. The cblC defect can be screened by measuring propionylcarnitine, propionylcarnitine-to-acetylcarnitine ratio combined with the second tier markers methylmalonic acid and tHcy. For the cblE and cblG defects, evidence for the benefit of early treatment is weaker; and data on performance of Met, Met/Phe and tHcy even more limited. Individuals homozygous or compound heterozygous for MAT1A mutations may benefit from detection by NBS using Met, which on the other hand also detects asymptomatic heterozygotes. Clinical and laboratory data is insufficient to develop any recommendation on NBS for the cblD, cblF, cblJ defects, glycineN-methyltransferase-, S-adenosylhomocysteinehydrolase- and adenosine kinase deficiency.
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Affiliation(s)
- Martina Huemer
- Division of Metabolism and Children's Research Center, University Children's Hospital Zürich, Zürich, Switzerland.
- Radiz-Rare Disease Initiative Zürich, University Zürich, Zürich, Switzerland.
- Department of Pediatrics, Landeskrankenhaus Bregenz, Carl-Pedenz-Str. 2, 6900, Bregenz, Austria.
| | - Viktor Kožich
- Institute of Inherited Metabolic Disorders, Charles University in Prague-1st Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Piero Rinaldo
- Department Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Matthias R Baumgartner
- Division of Metabolism and Children's Research Center, University Children's Hospital Zürich, Zürich, Switzerland
- Radiz-Rare Disease Initiative Zürich, University Zürich, Zürich, Switzerland
| | - Begoña Merinero
- Centro de Diagnóstico de Enfermedades Moleculares, Facultad de Ciencias, Universidad Autónoma de Madrid, IDIPAZ, CIBER de Enfermedades Raras, Madrid, Spain
| | - Elisabetta Pasquini
- Department of Neuroscience, Newborn Screening Unit, A. Meyer University Children's Hospital, Florence, Italy
| | - Antonia Ribes
- Division Inborn Errors of Metabolism, Hospital Clinic, CIBERER, Barcelona, Spain
| | - Henk J Blom
- Laboratory Clinical Biochemistry and Metabolism, Center for Pediatrics and Adolescent Medicine University Hospital, Freiburg, Freiburg, Germany
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Murphy E. Medical Problems in Obstetrics: Inherited Metabolic Disease. Best Pract Res Clin Obstet Gynaecol 2015; 29:707-20. [PMID: 26088792 DOI: 10.1016/j.bpobgyn.2015.04.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 04/06/2015] [Accepted: 04/07/2015] [Indexed: 11/26/2022]
Abstract
An increasing number of women with rare inherited disorders of metabolism are becoming pregnant. Although, in general, outcomes for women and their children are good, there are a number of issues that need to be considered. Currently, limited specific guidance on the management of these conditions in pregnancy is available. Prepregnancy counselling with information on inheritance, options for reproduction, teratogenicity risk, potential impact on maternal health and long-term health of children should be offered. With appropriate specialist management, the teratogenic risk of conditions such as maternal phenylketonuria (PKU) can be eliminated, and the risk of metabolic decompensation in disorders of energy metabolism or intoxication significantly reduced. Multidisciplinary management, and close liaison between obstetricians and other specialists, is required for those women in whom there is cardiac, renal, respiratory, joint or other organ involvement.
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Affiliation(s)
- Elaine Murphy
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK.
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Dayal S, Lentz SR. Homocysteine. Atherosclerosis 2015. [DOI: 10.1002/9781118828533.ch5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Lipid, Oxidative and Inflammatory Profile and Alterations in the Enzymes Paraoxonase and Butyrylcholinesterase in Plasma of Patients with Homocystinuria Due CBS Deficiency: The Vitamin B12 and Folic Acid Importance. Cell Mol Neurobiol 2015; 35:899-911. [DOI: 10.1007/s10571-015-0185-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 03/17/2015] [Indexed: 10/23/2022]
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