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Sait H, Srivastava S, Kumar S, Varughese B, Pandey M, Venkatramaiah M, Chaudhary P, Moirangthem A, Mandal K, Kapoor S. Inborn Errors of Ketogenesis: Novel Variants, Clinical Presentation, and Follow-Up in a Series of Four Patients. J Pediatr Genet 2024; 13:22-28. [PMID: 38567177 PMCID: PMC10984707 DOI: 10.1055/s-0042-1749362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 03/24/2022] [Indexed: 10/17/2022]
Abstract
Inborn errors of ketogenesis are rare disorders that result in acute and fulminant decompensation during lipolytic stress, particularly in infants and children. These include mitochondrial 3-hydroxy-3-methylglutaryl-CoA (HMG-CoA) synthase (HMGCS) deficiency and HMG-CoA lyase (HMGCL) deficiency. In this series, we describe the clinical, biochemical, and molecular profiles of four patients along with dietary interventions and their outcomes on a long-term follow-up. Two patients each of HMGCS and HMGCL deficiency were evaluated with clinical history, biochemical investigations, including tandem mass spectrometry (TMS) and urine gas chromatography-mass spectrometry (GCMS). Molecular analysis was performed by whole-exome sequencing, as well as exon array validated by long-range polymerase chain reaction. All individuals were diagnosed with acute metabolic decompensation in the early infancy period except one with HMGCL deficiency who had the first presentation at 5 years of age. Central nervous system manifestations, severe metabolic acidosis, hyperammonemia, hypoglycemia with a normal lactate, and absence of urinary ketones were observed in all the affected individuals. The disorder was life-threatening in three individuals and one succumbed to the illness. TMS was nonspecific and urine GCMS revealed dicarboxylic aciduria in HMGCS deficiency. Both the patients with HMGCL deficiency demonstrated elevated 3 hydroxyisovaleryl carnitine levels in TMS and metabolites of leucine degradation in urine GCMS. We identified five novel variants that included a large deletion involving exon 2 in HMGCL gene. There was no evidence of long-term neurological sequelae in the living individuals. Diet with moderation of fat intake was followed in two individuals with HMGCS deficiency. Low leucine and protein diet with moderation of fat intake was followed in the individual with HMGCL deficiency. All affected individuals are thriving well with no further major metabolic decompensation.
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Affiliation(s)
- Haseena Sait
- Department of Medical Genetics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Somya Srivastava
- Department of Medical Genetics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Somesh Kumar
- Division of Genetics and Metabolism, Department of Pediatrics, Lok Nayak Hospital, and Maulana Azad Medical College, New Delhi, India
| | - Bijo Varughese
- Division of Genetics and Metabolism, Department of Pediatrics, Lok Nayak Hospital, and Maulana Azad Medical College, New Delhi, India
| | - Manmohan Pandey
- Department of Medical Genetics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | | | - Parul Chaudhary
- Department of Medical Genetics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Amita Moirangthem
- Department of Medical Genetics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kausik Mandal
- Department of Medical Genetics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Seema Kapoor
- Division of Genetics and Metabolism, Department of Pediatrics, Lok Nayak Hospital, and Maulana Azad Medical College, New Delhi, India
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Abstract
The ketone bodies beta-hydroxybutyrate and acetoacetate are hepatically produced metabolites catabolized in extrahepatic organs. Ketone bodies are a critical cardiac fuel and have diverse roles in the regulation of cellular processes such as metabolism, inflammation, and cellular crosstalk in multiple organs that mediate disease. This review focuses on the role of cardiac ketone metabolism in health and disease with an emphasis on the therapeutic potential of ketosis as a treatment for heart failure (HF). Cardiac metabolic reprogramming, characterized by diminished mitochondrial oxidative metabolism, contributes to cardiac dysfunction and pathologic remodeling during the development of HF. Growing evidence supports an adaptive role for ketone metabolism in HF to promote normal cardiac function and attenuate disease progression. Enhanced cardiac ketone utilization during HF is mediated by increased availability due to systemic ketosis and a cardiac autonomous upregulation of ketolytic enzymes. Therapeutic strategies designed to restore high-capacity fuel metabolism in the heart show promise to address fuel metabolic deficits that underpin the progression of HF. However, the mechanisms involved in the beneficial effects of ketone bodies in HF have yet to be defined and represent important future lines of inquiry. In addition to use as an energy substrate for cardiac mitochondrial oxidation, ketone bodies modulate myocardial utilization of glucose and fatty acids, two vital energy substrates that regulate cardiac function and hypertrophy. The salutary effects of ketone bodies during HF may also include extra-cardiac roles in modulating immune responses, reducing fibrosis, and promoting angiogenesis and vasodilation. Additional pleotropic signaling properties of beta-hydroxybutyrate and AcAc are discussed including epigenetic regulation and protection against oxidative stress. Evidence for the benefit and feasibility of therapeutic ketosis is examined in preclinical and clinical studies. Finally, ongoing clinical trials are reviewed for perspective on translation of ketone therapeutics for the treatment of HF.
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Affiliation(s)
- Timothy R. Matsuura
- Cardiovascular Institute and Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Patrycja Puchalska
- Department of Medicine, Division of Molecular Medicine, University of Minnesota, Minneapolis, Minnesota 55455, USA
| | - Peter A. Crawford
- Department of Medicine, Division of Molecular Medicine, University of Minnesota, Minneapolis, Minnesota 55455, USA
- Department of Biochemistry, Molecular Biology, and Biophysics, University of Minnesota, Minneapolis, Minnesota 55455, USA
| | - Daniel P. Kelly
- Cardiovascular Institute and Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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Circadian clock controls rhythms in ketogenesis by interfering with PPARα transcriptional network. Proc Natl Acad Sci U S A 2022; 119:e2205755119. [PMID: 36161962 PMCID: PMC9546578 DOI: 10.1073/pnas.2205755119] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Ketone bodies are energy-rich metabolites and signaling molecules whose production is mainly regulated by diet. Caloric restriction (CR) is a dietary intervention that improves metabolism and extends longevity across the taxa. We found that CR induced high-amplitude daily rhythms in blood ketone bodies (beta-hydroxybutyrate [βOHB]) that correlated with liver βOHB level. Time-restricted feeding, another periodic fasting-based diet, also led to rhythmic βOHB but with reduced amplitude. CR induced strong circadian rhythms in the expression of fatty acid oxidation and ketogenesis genes in the liver. The transcriptional factor peroxisome-proliferator-activated-receptor α (PPARα) and its transcriptional target hepatokine fibroblast growth factor 21 (FGF21) are primary regulators of ketogenesis. Fgf21 expression and the PPARα transcriptional network became highly rhythmic in the CR liver, which implicated the involvement of the circadian clock. Mechanistically, the circadian clock proteins CLOCK, BMAL1, and cryptochromes (CRYs) interfered with PPARα transcriptional activity. Daily rhythms in the blood βOHB level and in the expression of PPARα target genes were significantly impaired in circadian clock-deficient Cry1,2-/- mice. These data suggest that blood βOHB level is tightly controlled and that the circadian clock is a regulator of diet-induced ketogenesis.
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Asif S, Kim RY, Fatica T, Sim J, Zhao X, Oh Y, Denoncourt A, Cheung A, Downey M, Mulvihill EE, Kim KH. Hmgcs2-mediated ketogenesis modulates high-fat diet-induced hepatosteatosis. Mol Metab 2022; 61:101494. [PMID: 35421611 PMCID: PMC9039870 DOI: 10.1016/j.molmet.2022.101494] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 04/01/2022] [Accepted: 04/04/2022] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE Aberrant ketogenesis is correlated with the degree of steatosis in NAFLD patients, and an inborn error of ketogenesis (mitochondrial HMG-CoA synthase deficiency) is commonly associated with the development of the fatty liver. Here we aimed to determine the impact of Hmgcs2-mediated ketogenesis and its modulations on the development and treatment of fatty liver disease. METHODS Loss- and gain-of-ketogenic function through in vivo and in vitro models, achieved by Hmgcs2 knockout and overexpression, respectively, were examined to investigate the role of ketogenesis in the hepatic lipid accumulation during neonatal development and the diet-induced NAFLD mouse model. RESULTS Ketogenic function was decreased in NAFLD mice with a reduction in Hmgcs2 expression. Mice lacking Hmgcs2 developed spontaneous fatty liver phenotype during postnatal development, which was rescued by a shift to a low-fat dietary composition via early weaning. Hmgcs2 heterozygous mice, which exhibited reduced ketogenic activity, were more susceptible to diet-induced NAFLD development, whereas HMGCS2 overexpression in NAFLD mice improved hepatosteatosis and glucose homeostasis. CONCLUSIONS Our study adds new knowledge to the field of ketone body metabolism and shows that Hmgcs2-mediated ketogenesis modulates hepatic lipid regulation under a fat-enriched nutritional environment. The regulation of hepatic ketogenesis may be a viable therapeutic strategy in the prevention and treatment of hepatosteatosis.
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Affiliation(s)
- Shaza Asif
- University of Ottawa Heart Institute, Ottawa, ON, K1Y 4W7, Canada; Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, K1H 8M5, Canada
| | - Ri Youn Kim
- University of Ottawa Heart Institute, Ottawa, ON, K1Y 4W7, Canada
| | - Thet Fatica
- University of Ottawa Heart Institute, Ottawa, ON, K1Y 4W7, Canada
| | - Jordan Sim
- Department of Pathology and Laboratory Medicine, The Ottawa Hospital, Ottawa, ON, K1H 8M5, Canada
| | - Xiaoling Zhao
- University of Ottawa Heart Institute, Ottawa, ON, K1Y 4W7, Canada
| | - Yena Oh
- University of Ottawa Heart Institute, Ottawa, ON, K1Y 4W7, Canada; Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, K1H 8M5, Canada
| | - Alix Denoncourt
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, K1H 8M5, Canada; Ottawa Institute of Systems Biology, Ottawa, ON, K1H 8M5, Canada
| | - Angela Cheung
- Gastroenterology and Hepatology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, K1H 8M5, Canada; The Ottawa Hospital Research Institute, Chronic Disease Program, Ottawa, ON, K1Y 4E9, Canada
| | - Michael Downey
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, K1H 8M5, Canada; Ottawa Institute of Systems Biology, Ottawa, ON, K1H 8M5, Canada
| | - Erin E Mulvihill
- University of Ottawa Heart Institute, Ottawa, ON, K1Y 4W7, Canada; Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, ON, K1H 8M5, Canada
| | - Kyoung-Han Kim
- University of Ottawa Heart Institute, Ottawa, ON, K1Y 4W7, Canada; Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, K1H 8M5, Canada.
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West N, Matiasek K, Rusbridge C. Olivopontocerebellar degeneration associated with 3-hydroxy-3-methylglutaric aciduria in a domestic shorthair cat. JFMS Open Rep 2021; 7:20551169211037899. [PMID: 34646570 PMCID: PMC8504233 DOI: 10.1177/20551169211037899] [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] [Indexed: 11/16/2022] Open
Abstract
CASE SUMMARY A rescue charity-owned 6-month-old neutered female domestic shorthair cat was presented with progressive tetraparesis, increased extensor muscle tone and signs of spinocerebellar ataxia, including hypermetria. The cat's male sibling, with similar progressive neurological signs, had been euthanased 2 months previously. An inherited metabolic disorder was suspected. Urine for determination of organic acid concentration was obtained and the cat was prescribed carnitine and taurine supplementation. The cat was euthanased 3 months later following progressive neurological signs, including ataxia, tetraparesis, tendency to fall, bilateral absent menace response and intention tremor. A selective post-mortem examination was obtained, taking samples from the brain, cervical spinal cord, tibial branch of the sciatic nerve, muscle, liver and kidneys. Organic acid analysis results received after euthanasia revealed a marked elevation of 3-hydroxy-3-methylglutaric acid (45 mmol/mol creatine [normal range 0-2]) and isovalerylglycine (27 mmol/mol creatinine [normal range 0-2]). 3-Hydroxy-3-methylglutaric acid was deemed clinically relevant as it is a metabolite of 3-hydroxy-3-methylglutaryl-CoA lyase, the enzyme involved in the final step of leucine degradation. Post-mortem examination revealed diffuse, chronic-active, severe olivoponto-(spino)-cerebellar degeneration. RELEVANCE AND NOVEL INFORMATION This is the first report of 3-hydroxy-3-methylglutaric aciduria in the veterinary literature and the first description of the neuropathology of this disorder in any species. 3-Hydroxy-3-methylglutaric aciduria in humans occurs rarely and is due to a deficiency in 3-hydroxy-3-methylglutaryl-coenzyme A lyase.
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Affiliation(s)
| | - Kaspar Matiasek
- Section of Clinical and Comparative Neuropathology, Centre for Clinical Veterinary Medicine, LMU Munich, Munich, Germany
| | - Clare Rusbridge
- School of Veterinary Medicine, Faculty of Health and Medical Science, Guildford, UK
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Sass JO, Grünert SC. Impaired ketone body utilisation as a cause of life-threatening ketoacidosis. Postgrad Med J 2021; 98:e21. [PMID: 33504614 DOI: 10.1136/postgradmedj-2021-139710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Jörn Oliver Sass
- Research Group Inborn Errors of Metabolism, Department of Natural Sciences & Institute for Functional Gene Analytics (IFGA), Bonn-Rhein-Sieg University of Applied Sciences, Rheinbach, Germany .,University College Dublin School of Biomolecular and Biomedical Science, Dublin, Ireland
| | - Sarah C Grünert
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
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Otsuka H, Kimura T, Ago Y, Nakama M, Aoyama Y, Abdelkreem E, Matsumoto H, Ohnishi H, Sasai H, Osawa M, Yamaguchi S, Mitchell GA, Fukao T. Deficiency of 3-hydroxybutyrate dehydrogenase (BDH1) in mice causes low ketone body levels and fatty liver during fasting. J Inherit Metab Dis 2020; 43:960-968. [PMID: 32279332 DOI: 10.1002/jimd.12243] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 04/05/2020] [Accepted: 04/08/2020] [Indexed: 02/05/2023]
Abstract
d-3-Hydroxy-n-butyrate dehydrogenase (BDH1; EC 1.1.1.30), encoded by BDH1, catalyzes the reversible reduction of acetoacetate (AcAc) to 3-hydroxybutyrate (3HB). BDH1 is the last enzyme of hepatic ketogenesis and the first enzyme of ketolysis. The hereditary deficiency of BDH1 has not yet been described in humans. To define the features of BDH1 deficiency in a mammalian model, we generated Bdh1-deficient mice (Bdh1 KO mice). Under normal housing conditions, with unrestricted access to food, Bdh1 KO mice showed normal growth, appearance, behavior, and fertility. In contrast, fasting produced marked differences from controls. Although Bdh1 KO mice survive fasting for at least 48 hours, blood 3HB levels remained very low in Bdh1 KO mice, and despite AcAc levels moderately higher than in controls, total ketone body levels in Bdh1 KO mice were significantly lower than in wild-type (WT) mice after 16, 24, and 48 hours fasting. Hepatic fat content at 24 hours of fasting was greater in Bdh1 KO than in WT mice. Systemic BDH1 deficiency was well tolerated under normal fed conditions but manifested during fasting with a marked increase in AcAc/3HB ratio and hepatic steatosis, indicating the importance of ketogenesis for lipid energy balance in the liver.
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Affiliation(s)
- Hiroki Otsuka
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu City, Japan
- Department of Neonatology, Gifu Prefectural General Medical Center, Gifu City, Japan
| | - Takeshi Kimura
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu City, Japan
| | - Yasuhiko Ago
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu City, Japan
| | - Mina Nakama
- Clinical Genetics Center, Gifu University Hospital, Gifu City, Japan
| | - Yuka Aoyama
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu City, Japan
- Department of Biomedical Sciences, College of Life and Health Sciences, Education and Training Center of Medical Technology, Chubu University, Kasugai City, Japan
| | - Elsayed Abdelkreem
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu City, Japan
- Department of Pediatrics, Faculty of Medicine, Sohag University, Nasser City, Egypt
| | - Hideki Matsumoto
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu City, Japan
| | - Hidenori Ohnishi
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu City, Japan
| | - Hideo Sasai
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu City, Japan
- Clinical Genetics Center, Gifu University Hospital, Gifu City, Japan
| | - Masatake Osawa
- Department of Regenerative Medicine and Applied Medical Sciences, Graduate School of Medicine, Gifu University, Gifu City, Japan
- Gifu Center for Highly Advanced Integration of Nanosciences and Life Sciences (G-CHAIN), Gifu University, Gifu City, Japan
| | - Seiji Yamaguchi
- Department of Pediatrics, Graduate School of Medicine, Shimane University, Izumo City, Japan
| | - Grant A Mitchell
- Division of Medical Genetics, Department of Pediatrics, CHU Sainte-Justine and Université de Montréal, Montréal, Quebec, Canada
| | - Toshiyuki Fukao
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu City, Japan
- Clinical Genetics Center, Gifu University Hospital, Gifu City, Japan
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2-methylacetoacetyl-coenzyme A thiolase (beta-ketothiolase) deficiency: one disease - two pathways. Orphanet J Rare Dis 2020; 15:106. [PMID: 32345314 PMCID: PMC7187484 DOI: 10.1186/s13023-020-01357-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/17/2020] [Indexed: 11/26/2022] Open
Abstract
Background 2-methylacetoacetyl-coenzyme A thiolase deficiency (MATD; deficiency of mitochondrial acetoacetyl-coenzyme A thiolase T2/ “beta-ketothiolase”) is an autosomal recessive disorder of ketone body utilization and isoleucine degradation due to mutations in ACAT1. Methods We performed a systematic literature search for all available clinical descriptions of patients with MATD. Two hundred forty-four patients were identified and included in this analysis. Clinical course and biochemical data are presented and discussed. Results For 89.6% of patients at least one acute metabolic decompensation was reported. Age at first symptoms ranged from 2 days to 8 years (median 12 months). More than 82% of patients presented in the first 2 years of life, while manifestation in the neonatal period was the exception (3.4%). 77.0% (157 of 204 patients) of patients showed normal psychomotor development without neurologic abnormalities. Conclusion This comprehensive data analysis provides a systematic overview on all cases with MATD identified in the literature. It demonstrates that MATD is a rather benign disorder with often favourable outcome, when compared with many other organic acidurias.
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Grünert SC, Sass JO. 3-hydroxy-3-methylglutaryl-coenzyme A lyase deficiency: one disease - many faces. Orphanet J Rare Dis 2020; 15:48. [PMID: 32059735 PMCID: PMC7023732 DOI: 10.1186/s13023-020-1319-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 01/28/2020] [Indexed: 11/23/2022] Open
Abstract
Background 3-hydroxy-3-methylglutaryl-coenzyme A lyase deficiency (HMGCLD) is an autosomal recessive disorder of ketogenesis and leucine degradation due to mutations in HMGCL. Method We performed a systematic literature search to identify all published cases. Two hundred eleven patients of whom relevant clinical data were available were included in this analysis. Clinical course, biochemical findings and mutation data are highlighted and discussed. An overview on all published HMGCL variants is provided. Results More than 95% of patients presented with acute metabolic decompensation. Most patients manifested within the first year of life, 42.4% already neonatally. Very few individuals remained asymptomatic. The neurologic long-term outcome was favorable with 62.6% of patients showing normal development. Conclusion This comprehensive data analysis provides a systematic overview on all published cases with HMGCLD including a list of all known HMGCL mutations.
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Affiliation(s)
- Sarah C Grünert
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center - University of Freiburg, Faculty of Medicine, Mathildenstr. 1, 79106, Freiburg, Germany.
| | - Jörn Oliver Sass
- Research Group Inborn Errors of Metabolism, Department of Natural Sciences & Institute for Functional Gene Analytics (IFGA), Bonn-Rhein-Sieg University of Applied Sciences, von-Liebig-Str. 20, 53359, Rheinbach, Germany.
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