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Posset R, Garbade SF, Gleich F, Scharre S, Okun JG, Gropman AL, Nagamani SCS, Druck AC, Epp F, Hoffmann GF, Kölker S, Zielonka M. Severity-adjusted evaluation of liver transplantation on health outcomes in urea cycle disorders. Genet Med 2024; 26:101039. [PMID: 38054409 DOI: 10.1016/j.gim.2023.101039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 12/07/2023] Open
Abstract
PURPOSE Liver transplantation (LTx) is performed in individuals with urea cycle disorders when medical management (MM) insufficiently prevents the occurrence of hyperammonemic events. However, there is a paucity of systematic analyses on the effects of LTx on health-related outcome parameters compared to individuals with comparable severity who are medically managed. METHODS We investigated the effects of LTx and MM on validated health-related outcome parameters, including the metabolic disease course, linear growth, and neurocognitive outcomes. Individuals were stratified into "severe" and "attenuated" categories based on the genotype-specific and validated in vitro enzyme activity. RESULTS LTx enabled metabolic stability by prevention of further hyperammonemic events after transplantation and was associated with a more favorable growth outcome compared with individuals remaining under MM. However, neurocognitive outcome in individuals with LTx did not differ from the medically managed counterparts as reflected by the frequency of motor abnormality and cognitive standard deviation score at last observation. CONCLUSION Whereas LTx enabled metabolic stability without further need of protein restriction or nitrogen-scavenging therapy and was associated with a more favorable growth outcome, LTx-as currently performed-was not associated with improved neurocognitive outcomes compared with long-term MM in the investigated urea cycle disorders.
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Affiliation(s)
- Roland Posset
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany.
| | - Sven F Garbade
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Florian Gleich
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Svenja Scharre
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Jürgen G Okun
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Andrea L Gropman
- Children's National Health System and The George Washington School of Medicine, Washington, DC
| | - Sandesh C S Nagamani
- Department of Molecular and Human Genetics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Ann-Catrin Druck
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Friederike Epp
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Georg F Hoffmann
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Kölker
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Zielonka
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany.
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2
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Posset R, Garbade SF, Gleich F, Nagamani SCS, Gropman AL, Epp F, Ramdhouni N, Druck AC, Hoffmann GF, Kölker S, Zielonka M. Impact of supplementation with L-citrulline/arginine after liver transplantation in individuals with Urea Cycle Disorders. Mol Genet Metab 2024; 141:108112. [PMID: 38301530 DOI: 10.1016/j.ymgme.2023.108112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/06/2023] [Accepted: 12/06/2023] [Indexed: 02/03/2024]
Abstract
OBJECTIVE Liver transplantation (LTx) is an intervention when medical management is not sufficiently preventing individuals with urea cycle disorders (UCDs) from the occurrence of hyperammonemic events. Supplementation with L-citrulline/arginine is regularly performed prior to LTx to support ureagenesis and is often continued after the intervention. However, systematic studies assessing the impact of long-term L-citrulline/arginine supplementation in individuals who have undergone LTx is lacking to date. METHODS Using longitudinal data collected systematically, a comparative analysis was carried out by studying the effects of long-term L-citrulline/arginine supplementation vs. no supplementation on health-related outcome parameters (i.e., anthropometric, neurological, and cognitive outcomes) in individuals with UCDs who have undergone LTx. Altogether, 52 individuals with male ornithine transcarbamylase deficiency, citrullinemia type 1 and argininosuccinic aciduria and a pre-transplant "severe" disease course who have undergone LTx were investigated by using recently established and validated genotype-specific in vitro enzyme activities. RESULTS Long-term supplementation of individuals with L-citrulline/arginine who have undergone LTx (n = 16) does neither appear to alter anthropometric nor neurocognitive endpoints when compared to their severity-adjusted counterparts that were not supplemented (n = 36) after LTx with mean observation periods between four to five years. Moreover, supplementation with L-citrulline/arginine was not associated with an increase of disease-specific plasma arithmetic mean values for the respective amino acids when compared to the non-supplemented control cohort. CONCLUSION Although supplementation with L-citrulline/arginine is often continued after LTx, this pilot study does neither identify altered long-term anthropometric or neurocognitive health-related outcomes nor does it find an adequate biochemical response as reflected by the unaltered plasma arithmetic mean values for L-citrulline or L-arginine. Further prospective analyses in larger samples and even longer observation periods will provide more insight into the usefulness of long-term supplementation with L-citrulline/arginine for individuals with UCDs who have undergone LTx.
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Affiliation(s)
- Roland Posset
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany.
| | - Sven F Garbade
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Florian Gleich
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Sandesh C S Nagamani
- Department of Molecular and Human Genetics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Andrea L Gropman
- Children's National Health System and The George Washington School of Medicine, Washington, DC, USA
| | - Friederike Epp
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Nesrine Ramdhouni
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Ann-Catrin Druck
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Georg F Hoffmann
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Stefan Kölker
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Matthias Zielonka
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany.
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3
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Aldrian D, Waldner B, Vogel GF, El-Gharbawy AH, McKiernan P, Vockley J, Landau YE, Al Mutairi F, Stepien KM, Kwok AMK, Yıldız Y, Honzik T, Kelifova S, Ellaway C, Lund AM, Mori M, Grünert SC, Scholl-Bürgi S, Zöggeler T, Oberhuber R, Schneeberger S, Müller T, Karall D. Impact of citrulline substitution on clinical outcome after liver transplantation in carbamoyl phosphate synthetase 1 and ornithine transcarbamylase deficiency. J Inherit Metab Dis 2024; 47:220-229. [PMID: 38375550 DOI: 10.1002/jimd.12717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 01/12/2024] [Accepted: 01/18/2024] [Indexed: 02/21/2024]
Abstract
Carbamoyl phosphate synthetase 1 (CPS1) and ornithine transcarbamylase (OTC) deficiencies are rare urea cycle disorders, which can lead to life-threatening hyperammonemia. Liver transplantation (LT) provides a cure and offers an alternative to medical treatment and life-long dietary restrictions with permanent impending risk of hyperammonemia. Nevertheless, in most patients, metabolic aberrations persist after LT, especially low plasma citrulline levels, with questionable clinical impact. So far, little is known about these alterations and there is no consensus, whether l-citrulline substitution after LT improves patients' symptoms and outcomes. In this multicentre, retrospective, observational study of 24 patients who underwent LT for CPS1 (n = 11) or OTC (n = 13) deficiency, 25% did not receive l-citrulline or arginine substitution. Correlation analysis revealed no correlation between substitution dosage and citrulline levels (CPS1, p = 0.8 and OTC, p = 1). Arginine levels after liver transplantation were normal after LT independent of citrulline substitution. Native liver survival had no impact on mental impairment (p = 0.67). Regression analysis showed no correlation between l-citrulline substitution and failure to thrive (p = 0.611) or neurological outcome (p = 0.701). Peak ammonia had a significant effect on mental impairment (p = 0.017). Peak plasma ammonia levels correlate with mental impairment after LT in CPS1 and OTC deficiency. Growth and intellectual impairment after LT are not significantly associated with l-citrulline substitution.
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Affiliation(s)
- Denise Aldrian
- Department of Paediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Birgit Waldner
- Department of Paediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Georg F Vogel
- Department of Paediatrics I, Medical University of Innsbruck, Innsbruck, Austria
- Institute of Cell Biology, Biocenter, Medical University of Innsbruck, Innsbruck, Austria
| | - Areeg H El-Gharbawy
- Division of Medical Genetics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Patrick McKiernan
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jerard Vockley
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yuval E Landau
- Metabolic Disease Unit, Schneider Children's Medical Center of Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Fuad Al Mutairi
- Genetics and Precision Medicine Department, King Abdullah Specialized Children Hospital, King Abdulaziz Medical City MNG-HA, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Karolina M Stepien
- Adult Inherited Metabolic Diseases, Salford Royal Organisation, Northern Care Alliance NHS Foundation Trust, Salford, Greater Manchester, UK
| | - Anne Mei-Kwun Kwok
- Department of Pediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Kowloon, Hong Kong
| | - Yılmaz Yıldız
- Division of Pediatric Metabolism, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Tomas Honzik
- Department of Pediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University, General University Hospital in Prague, Prague, Czech Republic
| | - Silvie Kelifova
- Department of Pediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University, General University Hospital in Prague, Prague, Czech Republic
| | - Carolyn Ellaway
- Genetic Metabolic Disorders Service, Sydney Children's Hospital Network, Sydney, New South Wales, Australia
- Disciplines of Child and Adolescent Health and Genomic Medicine, University of Sydney, Sydney, Australia
| | - Allan M Lund
- Departments of Clinical Genetics and Pediatrics, Center for Inherited Metabolic Diseases, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mari Mori
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Division of Genetic and Genomic Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Sarah C Grünert
- Department of General Paediatrics, Adolescent Medicine and Neonatology, Medical Centre-University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Sabine Scholl-Bürgi
- Department of Paediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Zöggeler
- Department of Paediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Rupert Oberhuber
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Müller
- Department of Paediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Daniela Karall
- Department of Paediatrics I, Medical University of Innsbruck, Innsbruck, Austria
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Seidl MJ, Scharre S, Posset R, Druck AC, Epp F, Okun JG, Dimitrov B, Hoffmann GF, Kölker S, Zielonka M. ASS1 deficiency is associated with impaired neuronal differentiation in zebrafish larvae. Mol Genet Metab 2024; 141:108097. [PMID: 38113552 DOI: 10.1016/j.ymgme.2023.108097] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 11/22/2023] [Accepted: 11/23/2023] [Indexed: 12/21/2023]
Abstract
Citrullinemia type 1 (CTLN1) is a rare autosomal recessive urea cycle disorder caused by deficiency of the cytosolic enzyme argininosuccinate synthetase 1 (ASS1) due to pathogenic variants in the ASS1 gene located on chromosome 9q34.11. Even though hyperammenomia is considered the major pathomechanistic factor for neurological impairment and cognitive dysfunction, a relevant subset of individuals presents with a neurodegenerative course in the absence of hyperammonemic decompensations. Here we show, that ASS1 deficiency induced by antisense-mediated knockdown of the zebrafish ASS1 homologue is associated with defective neuronal differentiation ultimately causing neuronal cell loss and consecutively decreased brain size in zebrafish larvae in vivo. Whereas ASS1-deficient zebrafish larvae are characterized by markedly elevated concentrations of citrulline - the biochemical hallmark of CTLN1, accumulation of L-citrulline, hyperammonemia or therewith associated secondary metabolic alterations did not account for the observed phenotype. Intriguingly, coinjection of the human ASS1 mRNA not only normalized citrulline concentration but also reversed the morphological cerebral phenotype and restored brain size, confirming conserved functional properties of ASS1 across species. The results of the present study imply a novel, potentially non-enzymatic (moonlighting) function of the ASS1 protein in neurodevelopment.
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Affiliation(s)
- Marie J Seidl
- Heidelberg University, Medical Faculty Heidelberg, and Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Svenja Scharre
- Heidelberg University, Medical Faculty Heidelberg, and Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Roland Posset
- Heidelberg University, Medical Faculty Heidelberg, and Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Ann-Catrin Druck
- Heidelberg University, Medical Faculty Heidelberg, and Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Friederike Epp
- Heidelberg University, Medical Faculty Heidelberg, and Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Jürgen G Okun
- Heidelberg University, Medical Faculty Heidelberg, and Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Bianca Dimitrov
- Heidelberg University, Medical Faculty Heidelberg, and Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Georg F Hoffmann
- Heidelberg University, Medical Faculty Heidelberg, and Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Kölker
- Heidelberg University, Medical Faculty Heidelberg, and Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Zielonka
- Heidelberg University, Medical Faculty Heidelberg, and Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Research Center for Molecular Medicine (HRCMM), Heidelberg, Germany.
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5
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Zhang Z, Tong F, Chen C, Zhang T, Qian G, Yang X, Huang X, Yang R, Zhao Z. Long-term follow-up of children with carbamoyl phosphate synthase 1 deficiency detected in newborn screening. Zhejiang Da Xue Xue Bao Yi Xue Ban 2023; 52:721-726. [PMID: 37986659 PMCID: PMC10764181 DOI: 10.3724/zdxbyxb-2023-0359] [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: 08/01/2023] [Accepted: 10/05/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVES To investigate genotype-phenotype characteristics and long-term prognosis of neonatal carbamoyl phosphate synthetase 1 (CPS1) deficiency among children through newborn screening in Zhejiang province. METHODS The clinical and follow-up data of children with CPS1 deficiency detected through neonatal screening and confirmed by tandem mass spectrometry and genetic testing in Zhejiang Province Newborn Disease Screening Center from September 2013 to August 2023 were retrospectively analyzed. RESULTS A total of 4 056 755 newborns were screened and 6 cases of CPS1 deficiency were diagnosed through phenotypic and genetic testing. Ten different variations of CPS1 genewere identified in genetic testing, including 2 known pathogenic variations (c.2359C>T and c.1549+1G>T) and 8 unreported variations (c.3405-1G>T, c.2372C>T, c.1436C>T, c.2228T>C, c.2441G>A, c.3031G>A, c.3075T>C and c.390-403del). All patients had decreased citrulline levels (2.72-6.21 μmol/L), and varying degrees of elevated blood ammonia. The patients received restricted natural protein intake (special formula), arginine and supportive therapy after diagnosis, and were followed-up for a period ranging from 9 months to 10 years. Three patients experienced hyperammonemia, and one patient each had attention deficit hyperactivity disorder, transient facial twitching and increased muscle tone. One patient died, while the other five surviving patients had normal scores of the Ages & Stages Questionnaires (ASQ) and Griffiths Development Scales up to the present time; 4 cases had combined height or weight lag and one case was normal in height and weight. CONCLUSIONS Low citrulline levels and hyperammonemia are common in CPS1 deficiency patients in Zhejiang. Most gene variants identified were specific to individual families, and no hotspot mutations were found. Early diagnosis through newborn screening and following standardized treatment can significantly improve the prognosis of the patients.
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Affiliation(s)
- Zhanming Zhang
- Department of Genetic and Metabolism,Children's Hospital,Zhejiang University School of Medicine,National Clinical Research Center for Child Health, Hangzhou 310052, China.
| | - Fan Tong
- Department of Genetic and Metabolism,Children's Hospital,Zhejiang University School of Medicine,National Clinical Research Center for Child Health, Hangzhou 310052, China
| | - Chi Chen
- Department of Genetic and Metabolism,Children's Hospital,Zhejiang University School of Medicine,National Clinical Research Center for Child Health, Hangzhou 310052, China
| | - Ting Zhang
- Department of Genetic and Metabolism,Children's Hospital,Zhejiang University School of Medicine,National Clinical Research Center for Child Health, Hangzhou 310052, China
| | - Guling Qian
- Department of Genetic and Metabolism,Children's Hospital,Zhejiang University School of Medicine,National Clinical Research Center for Child Health, Hangzhou 310052, China
| | - Xin Yang
- Department of Genetic and Metabolism,Children's Hospital,Zhejiang University School of Medicine,National Clinical Research Center for Child Health, Hangzhou 310052, China
| | - Xinwen Huang
- Department of Genetic and Metabolism,Children's Hospital,Zhejiang University School of Medicine,National Clinical Research Center for Child Health, Hangzhou 310052, China
| | - Rulai Yang
- Department of Genetic and Metabolism,Children's Hospital,Zhejiang University School of Medicine,National Clinical Research Center for Child Health, Hangzhou 310052, China
| | - Zhengyan Zhao
- Department of Genetic and Metabolism,Children's Hospital,Zhejiang University School of Medicine,National Clinical Research Center for Child Health, Hangzhou 310052, China.
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Posset R, Zielonka M, Gleich F, Garbade SF, Hoffmann GF, Kölker S. The challenge of understanding and predicting phenotypic diversity in urea cycle disorders. J Inherit Metab Dis 2023; 46:1007-1016. [PMID: 37702610 DOI: 10.1002/jimd.12678] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/31/2023] [Accepted: 09/05/2023] [Indexed: 09/14/2023]
Abstract
The Urea Cycle Disorders Consortium (UCDC) and the European registry and network for Intoxication type Metabolic Diseases (E-IMD) are the worldwide largest databases for individuals with urea cycle disorders (UCDs) comprising longitudinal data from more than 1100 individuals with an overall long-term follow-up of approximately 25 years. However, heterogeneity of the clinical phenotype as well as different diagnostic and therapeutic strategies hamper our understanding on the predictors of phenotypic diversity and the impact of disease-immanent and interventional variables (e.g., diagnostic and therapeutic interventions) on the long-term outcome. A new strategy using combined and comparative data analyses helped overcome this challenge. This review presents the mechanisms and relevant principles that are necessary for the identification of meaningful clinical associations by combining data from different data sources, and serves as a blueprint for future analyses of rare disease registries.
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Affiliation(s)
- Roland Posset
- Division of Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Zielonka
- Division of Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
- Heidelberg Research Center for Molecular Medicine (HRCMM), Heidelberg, Germany
| | - Florian Gleich
- Division of Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Sven F Garbade
- Division of Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Georg F Hoffmann
- Division of Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Kölker
- Division of Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
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7
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Leal AF, Fnu N, Benincore-Flórez E, Herreño-Pachón AM, Echeverri-Peña OY, Alméciga-Díaz CJ, Tomatsu S. The landscape of CRISPR/Cas9 for inborn errors of metabolism. Mol Genet Metab 2023; 138:106968. [PMID: 36525790 DOI: 10.1016/j.ymgme.2022.106968] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 12/03/2022] [Accepted: 12/04/2022] [Indexed: 12/12/2022]
Abstract
Since its discovery as a genome editing tool, the clustered regularly interspaced short palindromic repeats and CRISPR-associated protein 9 (CRISPR/Cas9) system has opened new horizons in the diagnosis, research, and treatment of genetic diseases. CRISPR/Cas9 can rewrite the genome at any region with outstanding precision to modify it and further instructions for gene expression. Inborn Errors of Metabolism (IEM) are a group of more than 1500 diseases produced by mutations in genes encoding for proteins that participate in metabolic pathways. IEM involves small molecules, energetic deficits, or complex molecules diseases, which may be susceptible to be treated with this novel tool. In recent years, potential therapeutic approaches have been attempted, and new models have been developed using CRISPR/Cas9. In this review, we summarize the most relevant findings in the scientific literature about the implementation of CRISPR/Cas9 in IEM and discuss the future use of CRISPR/Cas9 to modify epigenetic markers, which seem to play a critical role in the context of IEM. The current delivery strategies of CRISPR/Cas9 are also discussed.
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Affiliation(s)
- Andrés Felipe Leal
- Institute for the Study of Inborn Errors of Metabolism, Faculty of Science, Pontificia Universidad Javeriana, Bogotá, Colombia; Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Nidhi Fnu
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA; University of Delaware, Newark, DE, USA
| | | | | | - Olga Yaneth Echeverri-Peña
- Institute for the Study of Inborn Errors of Metabolism, Faculty of Science, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Carlos Javier Alméciga-Díaz
- Institute for the Study of Inborn Errors of Metabolism, Faculty of Science, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Shunji Tomatsu
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA; University of Delaware, Newark, DE, USA; Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan; Department of Pediatrics, Thomas Jefferson University, Philadelphia, PA, USA.
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8
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Scharre S, Posset R, Garbade SF, Gleich F, Seidl MJ, Druck A, Okun JG, Gropman AL, Nagamani SCS, Hoffmann GF, Kölker S, Zielonka M. Predicting the disease severity in male individuals with ornithine transcarbamylase deficiency. Ann Clin Transl Neurol 2022; 9:1715-1726. [PMID: 36217298 PMCID: PMC9639638 DOI: 10.1002/acn3.51668] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 09/01/2022] [Accepted: 09/06/2022] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE Ornithine transcarbamylase deficiency (OTC-D) is an X-linked metabolic disease and the most common urea cycle disorder. Due to high phenotypic heterogeneity, ranging from lethal neonatal hyperammonemic events to moderate symptoms and even asymptomatic individuals, the prediction of the disease course at an early disease stage is very important to individually adjust therapies such as medical treatment or liver transplantation. In this translational study, we developed a severity-adjusted classification system based on in vitro residual enzymatic OTC activity. METHODS Applying a cell-based expression system, residual enzymatic OTC activities of 71 pathogenic OTC variants were spectrophotometrically determined and subsequently correlated with clinical and biochemical outcome parameters of 119 male individuals with OTC-D (mOTC-D) as reported in the UCDC and E-IMD registries. RESULTS Integration of multiple data sources enabled the establishment of a robust disease prediction model for mOTC-D. Residual enzymatic OTC activity not only correlates with age at first symptoms, initial peak plasma ammonium concentration and frequency of metabolic decompensations but also predicts mortality. The critical threshold of 4.3% residual enzymatic activity distinguishes a severe from an attenuated phenotype. INTERPRETATION Residual enzymatic OTC activity reliably predicts the disease severity in mOTC-D and could thus serve as a tool for severity-adjusted evaluation of therapeutic strategies and counselling patients and parents.
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Affiliation(s)
- Svenja Scharre
- Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent MedicineUniversity Hospital HeidelbergHeidelbergGermany
| | - Roland Posset
- Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent MedicineUniversity Hospital HeidelbergHeidelbergGermany
| | - Sven F. Garbade
- Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent MedicineUniversity Hospital HeidelbergHeidelbergGermany
| | - Florian Gleich
- Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent MedicineUniversity Hospital HeidelbergHeidelbergGermany
| | - Marie J. Seidl
- Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent MedicineUniversity Hospital HeidelbergHeidelbergGermany
| | - Ann‐Catrin Druck
- Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent MedicineUniversity Hospital HeidelbergHeidelbergGermany
| | - Jürgen G. Okun
- Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent MedicineUniversity Hospital HeidelbergHeidelbergGermany
| | - Andrea L. Gropman
- Division of Neurodevelopmental Pediatrics and Neurogenetics, Children's National Health System and The George Washington School of MedicineWashingtonDistrict of ColumbiaUSA
| | - Sandesh C. S. Nagamani
- Department of Molecular and Human GeneticsBaylor College of Medicine and Texas Children's HospitalHoustonTexasUSA
| | - Georg F. Hoffmann
- Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent MedicineUniversity Hospital HeidelbergHeidelbergGermany
| | - Stefan Kölker
- Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent MedicineUniversity Hospital HeidelbergHeidelbergGermany
| | - Matthias Zielonka
- Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent MedicineUniversity Hospital HeidelbergHeidelbergGermany
- Heidelberg Research Center for Molecular Medicine (HRCMM)HeidelbergGermany
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9
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Bin Sawad A, Jackimiec J, Bechter M, Trucillo A, Lindsley K, Bhagat A, Uyei J, Diaz GA. Epidemiology, methods of diagnosis, and clinical management of patients with arginase 1 deficiency (ARG1-D): A systematic review. Mol Genet Metab 2022; 137:153-163. [PMID: 36049366 DOI: 10.1016/j.ymgme.2022.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/18/2022] [Accepted: 08/20/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Arginase 1 Deficiency (ARG1-D) is a rare, progressive, metabolic disorder that is characterized by devastating manifestations driven by elevated plasma arginine levels. It typically presents in early childhood with spasticity (predominately affecting the lower limbs), mobility impairment, seizures, developmental delay, and intellectual disability. This systematic review aims to identify and describe the published evidence outlining the epidemiology, diagnosis methods, measures of disease progression, clinical management, and outcomes for ARG1-D patients. METHODS A comprehensive literature search across multiple databases such as MEDLINE, Embase, and a review of clinical studies in ClinicalTrials.gov (with results reported) was carried out per PRISMA guidelines on 20 April 2020 with no date restriction. Pre-defined eligibility criteria were used to identify studies with data specific to patients with ARG1-D. Two independent reviewers screened records and extracted data from included studies. Quality was assessed using the modified Newcastle-Ottawa Scale for non-comparative studies. RESULTS Overall, 55 records reporting 40 completed studies and 3 ongoing studies were included. Ten studies reported the prevalence of ARG1-D in the general population, with a median of 1 in 1,000,000. Frequently reported diagnostic methods included genetic testing, plasma arginine levels, and red blood cell arginase activity. However, routine newborn screening is not universally available, and lack of disease awareness may prevent early diagnosis or lead to misdiagnosis, as the disease has overlapping symptomology with other diseases, such as cerebral palsy. Common manifestations reported at time of diagnosis and assessed for disease progression included spasticity (predominately affecting the lower limbs), mobility impairment, developmental delay, intellectual disability, and seizures. Severe dietary protein restriction, essential amino acid supplementation, and nitrogen scavenger administration were the most commonly reported treatments among patients with ARG1-D. Only a few studies reported meaningful clinical outcomes of these interventions on intellectual disability, motor function and adaptive behavior assessment, hospitalization, or death. The overall quality of included studies was assessed as good according to the Newcastle-Ottawa Scale. CONCLUSIONS Although ARG1-D is a rare disease, published evidence demonstrates a high burden of disease for patients. The current standard of care is ineffective at preventing disease progression. There remains a clear need for new treatment options as well as improved access to diagnostics and disease awareness to detect and initiate treatment before the onset of clinical manifestations to potentially enable more normal development, improve symptomatology, or prevent disease progression.
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Affiliation(s)
| | | | | | | | | | | | | | - George A Diaz
- Division of Medical Genetics and Genomics in the Department of Genetics and Genomic Sciences at the Icahn School of Medicine at Mount Sinai, New York, NY, USA
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10
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Scharping M, Brennenstuhl H, Garbade SF, Wild B, Posset R, Zielonka M, Kölker S, Haun MW, Opladen T. Unmet Needs of Parents of Children with Urea Cycle Disorders. CHILDREN 2022; 9:children9050712. [PMID: 35626889 PMCID: PMC9140128 DOI: 10.3390/children9050712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/03/2022] [Accepted: 05/09/2022] [Indexed: 12/26/2022]
Abstract
(1) Background: Phenotypic diversity and long-term health outcomes of individuals with urea cycle disorders (UCDs) have been described in detail. However, there is limited information on the burden on affected families. (2) Methods: To evaluate the family burden in parents with children suffering from UCDs, we used validated questionnaires. Socio-demographic characteristics were evaluated, and an adapted version of the Parental Need Scale for Rare Diseases questionnaire was used. The survey was conducted in families of UCD patients cared for at the University Children’s Hospital Heidelberg. (3) Results: From April to November 2021, 59 participants were interviewed (mothers n = 34, fathers n = 25). The affected patients most frequently suffered from ornithine transcarbamylase deficiency (OTC-D) (female n = 12, male n = 12), followed by argininosuccinate synthetase deficiency (ASS-D, n = 13) and argininosuccinate lyase deficiency (ASL-D, n = 8). About one-third of the participants were “dissatisfied” or “extremely dissatisfied” with health professionals’ disease knowledge. In addition, 30% of the participants reported a medium or high need for “additional information on the development of their children”, and 44% reported a medium or high need “for information on available services”. A majority of 68% reported a need for additional support regarding services such as support groups (42%) or psychological counseling (29%). (4) Conclusions: Our study indicates that there is an unmet need for sufficient information about the development of children with UCDs, as well as for information about available support services for families with UCD patients. Furthermore, the results highlight the importance of establishing or improving family-centered care approaches. This pilot study may serve as a template for the assessment of the family burden associated with other inherited metabolic diseases.
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Affiliation(s)
- Mara Scharping
- Division of Child Neurology and Metabolic Medicine, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.S.); (H.B.); (S.F.G.); (R.P.); (M.Z.); (S.K.)
| | - Heiko Brennenstuhl
- Division of Child Neurology and Metabolic Medicine, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.S.); (H.B.); (S.F.G.); (R.P.); (M.Z.); (S.K.)
| | - Sven F. Garbade
- Division of Child Neurology and Metabolic Medicine, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.S.); (H.B.); (S.F.G.); (R.P.); (M.Z.); (S.K.)
| | - Beate Wild
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, 69120 Heidelberg, Germany; (B.W.); (M.W.H.)
| | - Roland Posset
- Division of Child Neurology and Metabolic Medicine, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.S.); (H.B.); (S.F.G.); (R.P.); (M.Z.); (S.K.)
| | - Matthias Zielonka
- Division of Child Neurology and Metabolic Medicine, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.S.); (H.B.); (S.F.G.); (R.P.); (M.Z.); (S.K.)
| | - Stefan Kölker
- Division of Child Neurology and Metabolic Medicine, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.S.); (H.B.); (S.F.G.); (R.P.); (M.Z.); (S.K.)
| | - Markus W. Haun
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, 69120 Heidelberg, Germany; (B.W.); (M.W.H.)
| | - Thomas Opladen
- Division of Child Neurology and Metabolic Medicine, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.S.); (H.B.); (S.F.G.); (R.P.); (M.Z.); (S.K.)
- Correspondence:
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11
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Calvo-López A, Rebollo-Calderon B, Ormazábal A, Artuch R, Rosell-Ferrer J, Alonso-Chamarro J, Puyol M. Biomedical point-of-care microanalyzer for potentiometric determination of ammonium ion in plasma and whole blood. Anal Chim Acta 2022; 1205:339782. [DOI: 10.1016/j.aca.2022.339782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 03/24/2022] [Accepted: 03/26/2022] [Indexed: 11/01/2022]
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12
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Santamaria R, Ballester M, Garcia-Llorens G, Martinez F, Blazquez M, Ribes-Koninckx C, Castell JV, Wuestefeld T, Bort R. Derivation of healthy hepatocyte-like cells from a female patient with ornithine transcarbamylase deficiency through X-inactivation selection. Sci Rep 2022; 12:2308. [PMID: 35145162 PMCID: PMC8831560 DOI: 10.1038/s41598-022-06184-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 01/18/2022] [Indexed: 11/09/2022] Open
Abstract
Autologous cell replacement therapy for inherited metabolic disorders requires the correction of the underlying genetic mutation in patient's cells. An unexplored alternative for females affected from X-linked diseases is the clonal selection of cells randomly silencing the X-chromosome containing the mutant allele, without in vivo or ex vivo genome editing. In this report, we have isolated dermal fibroblasts from a female patient affected of ornithine transcarbamylase deficiency and obtained clones based on inactivation status of either maternally or paternally inherited X chromosome, followed by differentiation to hepatocytes. Hepatocyte-like cells derived from these clones display indistinct features characteristic of hepatocytes, but express either the mutant or wild type OTC allele depending on X-inactivation pattern. When clonally derived hepatocyte-like cells were transplanted into FRG® KO mice, they were able to colonize the liver and recapitulate OTC-dependent phenotype conditioned by X-chromosome inactivation pattern. This approach opens new strategies for cell therapy of X-linked metabolic diseases and experimental in vitro models for drug development for such diseases.
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Affiliation(s)
- Ramon Santamaria
- Experimental Hepatology Unit, Instituto de Investigación Sanitaria La Fe, CIBERehd, Hospital Universitari i Politècnic La Fe, Avda. Fernando Abril Martorell 106, 46026, Valencia, Spain
| | - Maria Ballester
- Experimental Hepatology Unit, Instituto de Investigación Sanitaria La Fe, CIBERehd, Hospital Universitari i Politècnic La Fe, Avda. Fernando Abril Martorell 106, 46026, Valencia, Spain
| | - Guillem Garcia-Llorens
- Experimental Hepatology Unit, Instituto de Investigación Sanitaria La Fe, CIBERehd, Hospital Universitari i Politècnic La Fe, Avda. Fernando Abril Martorell 106, 46026, Valencia, Spain
- Biochemistry and Molecular Biology Department, Universidad de Valencia, Valencia, Spain
| | - Francisco Martinez
- Genetics Unit, Instituto de Investigación Sanitaria La Fe, Hospital Universitari i Politècnic La Fe, 46026, Valencia, Spain
| | - Marina Blazquez
- Experimental Hepatology Unit, Instituto de Investigación Sanitaria La Fe, CIBERehd, Hospital Universitari i Politècnic La Fe, Avda. Fernando Abril Martorell 106, 46026, Valencia, Spain
| | - Carmen Ribes-Koninckx
- Coeliac Disease and Inmunopathology Research Unit, Instituto de Investigación Sanitaria La Fe, Pediatric Gastroenterology, Hospital Universitari i Politècnic La Fe, 46026, Valencia, Spain
| | - Jose V Castell
- Experimental Hepatology Unit, Instituto de Investigación Sanitaria La Fe, CIBERehd, Hospital Universitari i Politècnic La Fe, Avda. Fernando Abril Martorell 106, 46026, Valencia, Spain
- Biochemistry and Molecular Biology Department, Universidad de Valencia, Valencia, Spain
| | - Torsten Wuestefeld
- Laboratory for In Vivo Genetics & Gene Therapy, Genome Institute of Singapore, A*STAR & National Cancer Centre Singapore, School of Biological Science, SingHealth & Adj. Ass.-Prof. Nanyang Technological University, 60 Biopolis Street, #02-01 Genome, Singapore, 138672, Singapore
| | - Roque Bort
- Experimental Hepatology Unit, Instituto de Investigación Sanitaria La Fe, CIBERehd, Hospital Universitari i Politècnic La Fe, Avda. Fernando Abril Martorell 106, 46026, Valencia, Spain.
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13
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Choi Y, Oh A, Lee Y, Kim GH, Choi JH, Yoo HW, Lee BH. Unfavorable clinical outcomes in patients with carbamoyl phosphate synthetase 1 deficiency. Clin Chim Acta 2021; 526:55-61. [PMID: 34973183 DOI: 10.1016/j.cca.2021.11.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/22/2021] [Accepted: 11/30/2021] [Indexed: 12/31/2022]
Abstract
PURPOSE Carbamoyl phosphate synthetase 1 (CPS1) deficiency affects the first step of urea cycle and is a severe form of urea cycle disorder (UCD). The severity of hyperammonemic encephalopathy determines the clinical course of UCDs. Here, we describe the genetic and clinical characteristics of CPS1 deficiency in Korea. PATIENT AND METHODS This study included seven patients with CPS1 deficiency genetically confirmed from January 1992 to September 2020. The peak ammonia level during the first crisis, the half time of peak ammonia level, the initial plasma amino acid levels, and neurological outcomes were compared between CPS1 deficiency and two common UCDs (i.e., 17 patients with argininosuccinate synthetase 1 deficiency and 24 patients with ornithine transcarbamylase deficiency). RESULT Eleven CPS1 mutations were identified, including 10 novel mutations. Eight mutations were missense. Six patients with CPS1 deficiency had neonatal type. The peak ammonia level, initial glutamate level, and accompanying rate of irreversible neurological damages were highest in patients with CPS1 deficiency. The patient with late-onset CPS1 deficiency responded dramatically to N-carbamylglutamate treatment. CONCLUSION The clinical manifestations of CPS1 deficiency were the most severe among UCDs. Considering the high proportion of missense mutations, responsiveness to N-carbamylglutamate would be evaluated in a future study.
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Affiliation(s)
- Yunha Choi
- Department of Pediatrics, Medical Genetics Center, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea
| | - Arum Oh
- Department of Pediatrics, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, South Korea
| | - Yena Lee
- Department of Pediatrics, Medical Genetics Center, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea
| | - Gu-Hwan Kim
- Medical Genetics Center, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jin-Ho Choi
- Department of Pediatrics, Medical Genetics Center, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea
| | - Han-Wook Yoo
- Department of Pediatrics, Medical Genetics Center, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea; Medical Genetics Center, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea
| | - Beom Hee Lee
- Department of Pediatrics, Medical Genetics Center, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea; Medical Genetics Center, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea.
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14
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Nitzahn M, Truong B, Khoja S, Vega-Crespo A, Le C, Eliav A, Makris G, Pyle AD, Häberle J, Lipshutz GS. CRISPR-Mediated Genomic Addition to CPS1 Deficient iPSCs is Insufficient to Restore Nitrogen Homeostasis. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2021; 94:545-557. [PMID: 34970092 PMCID: PMC8686786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
CPS1 deficiency is an inborn error of metabolism caused by loss-of-function mutations in the CPS1 gene, catalyzing the initial reaction of the urea cycle. Deficiency typically leads to toxic levels of plasma ammonia, cerebral edema, coma, and death, with the only curative treatment being liver transplantation; due to limited donor availability and the invasiveness and complications of the procedure, however, alternative therapies are needed. Induced pluripotent stem cells offer an alternative cell source to partial or whole liver grafts that theoretically would not require immune suppression regimens and additionally are amenable to genetic modifications. Here, we genetically modified CPS1 deficient patient-derived stem cells to constitutively express human codon optimized CPS1 from the AAVS1 safe harbor site. While edited stem cells efficiently differentiated to hepatocyte-like cells, they failed to metabolize ammonia more efficiently than their unedited counterparts. This unexpected result appears to have arisen in part due to transgene promoter methylation, and thus transcriptional silencing, in undifferentiated cells, impacting their capacity to restore the complete urea cycle function upon differentiation. As pluripotent stem cell strategies are being expanded widely for potential cell therapies, these results highlight the need for strict quality control and functional analysis to ensure the integrity of cell products.
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Affiliation(s)
- Matthew Nitzahn
- Molecular Biology Institute, David Geffen School of
Medicine at UCLA, Los Angeles, CA, USA,Department of Surgery, David Geffen School of Medicine
at UCLA, Los Angeles, CA, USA
| | - Brian Truong
- Department of Surgery, David Geffen School of Medicine
at UCLA, Los Angeles, CA, USA,Department of Molecular and Medical Pharmacology, David
Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Suhail Khoja
- Department of Surgery, David Geffen School of Medicine
at UCLA, Los Angeles, CA, USA
| | - Agustin Vega-Crespo
- Department of Molecular and Medical Pharmacology, David
Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Colleen Le
- Department of Surgery, David Geffen School of Medicine
at UCLA, Los Angeles, CA, USA
| | - Adam Eliav
- Department of Surgery, David Geffen School of Medicine
at UCLA, Los Angeles, CA, USA
| | - Georgios Makris
- Division of Metabolism and Children’s Research Center,
University Children’s Hospital Zurich, Switzerland
| | - April D. Pyle
- Department of Microbiology, Immunology, and Molecular
Genetics, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA,Eli and Edythe Broad Stem Cell Center, David Geffen
School of Medicine at UCLA, Los Angeles, CA, USA
| | - Johannes Häberle
- Division of Metabolism and Children’s Research Center,
University Children’s Hospital Zurich, Switzerland
| | - Gerald S. Lipshutz
- Molecular Biology Institute, David Geffen School of
Medicine at UCLA, Los Angeles, CA, USA,Department of Surgery, David Geffen School of Medicine
at UCLA, Los Angeles, CA, USA,Department of Molecular and Medical Pharmacology, David
Geffen School of Medicine at UCLA, Los Angeles, CA, USA,Department of Psychiatry, David Geffen School of
Medicine at UCLA, Los Angeles, CA, USA,Intellectual and Developmental Disabilities Research
Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA,Semel Institute for Neuroscience, David Geffen School
of Medicine at UCLA, Los Angeles, CA, USA,To whom all correspondence should be addressed:
Gerald S. Lipshutz, David Geffen School of Medicine at UCLA, Los Angeles, CA
90095-7054;
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15
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Toquet S, Spodenkiewicz M, Douillard C, Maillot F, Arnoux JB, Damaj L, Odent S, Moreau C, Redonnet-Vernhet I, Mesli S, Servais A, Noel E, Charriere S, Rigalleau V, Lavigne C, Kaphan E, Roubertie A, Besson G, Bigot A, Servettaz A, Mochel F, Garnotel R. Adult-onset diagnosis of urea cycle disorders: Results of a French cohort of 71 patients. J Inherit Metab Dis 2021; 44:1199-1214. [PMID: 34014557 DOI: 10.1002/jimd.12403] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 05/14/2021] [Accepted: 05/18/2021] [Indexed: 12/19/2022]
Abstract
Urea cycle disorders (UCD) are rare diseases that usually affect neonates or young children. During decompensations, hyperammonemia is neurotoxic, leading to severe symptoms and even coma and death if not treated rapidly. The aim was to describe a cohort of patients with adult onset of UCDs in a multicentric, retrospective and descriptive study of French adult patients with a diagnosis after 16 years of age of UCDs due to a deficiency in one of the 6 enzymes (arginase, ASL, ASS, CPS1, NAGS, OTC) or the two transporters (ORNT1 or citrin). Seventy-one patients were included (68% female, 32% male). The diagnosis was made in the context of (a) a metabolic decompensation (42%), (b) family history (55%), or (c) chronic symptoms (3%). The median age at diagnosis was 33 years (range 16-86). Eighty-nine percent of patients were diagnosed with OTC deficiency, 7% CPS1 deficiency, 3% HHH syndrome and 1% argininosuccinic aciduria. For those diagnosed during decompensations (including 23 OTC cases, mostly female), 89% required an admission in intensive care units. Seven deaths were attributed to UCD-6 decompensations and 1 epilepsy secondary to inaugural decompensation. This is the largest cohort of UCDs diagnosed in adulthood, which confirms the triad of neurological, gastrointestinal and psychiatric symptoms during hyperammonemic decompensations. We stress that females with OTC deficiency can be symptomatic. With 10% of deaths in this cohort, UCDs in adults remain a life-threatening condition. Physicians working in adult care must be aware of late-onset presentations given the implications for patients and their families.
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Affiliation(s)
- Ségolène Toquet
- Service de Médecine Interne, Hôpital Robert Debré, CHU Reims, France
| | | | - Claire Douillard
- Service d'Endocrinologie et Métabolismes, Hôpital Claude Huriez, Centre de Référence des Maladies Héréditaires du métabolisme, CHU Lille, France
| | - François Maillot
- Service de Médecine Interne, Hôpital Bretonneau, CHRU de Tours, France
| | - Jean-Baptiste Arnoux
- Centre de Référence des Maladies Héréditaires du Métabolisme, Hôpital Necker-Enfants Malades, CHU Paris, France
| | - Lena Damaj
- Service de Pédiatrie, CHU Hôpital Sud, Rennes, France
| | - Sylvie Odent
- Service de Génétique Clinique, CHU Hôpital Sud, Rennes, France
| | - Caroline Moreau
- Service de Biochimie et Toxicologie, CHU Pontchaillou, Rennes, France
| | | | - Samir Mesli
- Laboratoire de Biochimie, Hôpital Pellegrin, CHU Bordeaux, France
| | - Aude Servais
- Service de Néphrologie adulte, Hôpital Necker-Enfants Malades, CHU Paris, France
| | - Esther Noel
- Service de Médecine Interne, Hôpital Universitaire de Strasbourg, CHRU Strasbourg, France
| | - Sybill Charriere
- Fédération d'endocrinologie, maladies métaboliques, diabète et nutrition, Hôpital Louis Pradel, Centre de Référence des Maladies Héréditaires du Métabolisme, Bron, France
| | | | | | - Elsa Kaphan
- Pôle de Neurosciences Cliniques, CHU Timone, AP-HM, Marseille, France
| | - Agathe Roubertie
- Département de neuropédiatrie, Hôpital Gui de Chauliac, CHU Montpellier, France
| | | | - Adrien Bigot
- Service de Médecine Interne, Hôpital Bretonneau, CHRU de Tours, France
| | - Amélie Servettaz
- Service de Médecine Interne, Hôpital Robert Debré, CHU Reims, France
| | - Fanny Mochel
- Département de génétique, Hôpital Pitié-Salpêtrière, CHU Paris, France
| | - Roselyne Garnotel
- Laboratoire de Biochimie-Pharmacologie-Toxicologie, CHU Reims, France
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16
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New ratio as a useful marker for early diagnosis of proximal urea cycle disorders. Clin Chim Acta 2021; 520:154-159. [PMID: 34116006 DOI: 10.1016/j.cca.2021.06.011] [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: 05/10/2021] [Revised: 06/04/2021] [Accepted: 06/05/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND AIMS Proximal urea cycle disorders (PUCDs) are not included in most newborn screening programs due to the lack of adequate markers to monitor. Failure to alter citrulline and glutamine levels, the prognostic markers commonly used, can results in high false negative. Therefore, new biomarkers, prognostic of PUCDs, are strongly desirable. MATERIALS AND METHODS We used tandem mass spectrometry to analyze blood spot from PUCDs patients during their follow up in our referral center focusing on glutamine to glutamate (Gln/Glu) ratio. We reanalyzed the same specimens of three patients after two months and the specimen of a new patient with suspicious of PUCD disorder. RESULTS Specimens of our patients shown a significant elevation of the ratio Gln/Glu compared to that of a healthy population (p < 0.05) as well as the specimens analyzed after two months, while the glutamine concentration dropped. New patient, showing high value of the ratio, was molecularly confirmed as PUCD patient. We further analyzed the blood spots from a neonatal population in order to fix a cut-off value and include it in a newborn screening panel. CONCLUSION Our preliminary results suggest that the Gln/Glu ratio could be a very useful diagnostic marker, more stable over time than glutamine, which could improve the performance in early PUCDs identification.
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17
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Liu Y, Luo Y, Xia L, Qiu B, Zhou T, Feng M, Wang C, Xue F, Chen X, Han L, Zhang J, Xia Q. Outcome of Liver Transplantation for Neonatal-onset Citrullinemia Type I. Transplantation 2021; 105:569-576. [PMID: 33617202 DOI: 10.1097/tp.0000000000003261] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND We evaluated the outcome of liver transplantation (LT) in neonatal-onset citrullinemia type I patients, especially its impact on neurological deficits and developmental retardation. METHODS From October 2006 to October 2019, 5 of the 2003 children who received LT at Ren Ji Hospital had been diagnosed with citrullinemia type I. The primary indication for transplantation was repeated metabolic compensation and developmental retardation in 4 patients and prophylactic transplantation in the other. Among them, 3 patients received living donor LT and 2 received orthotopic LT. RESULTS All recipients had successfully recovered within the median follow-up period of 32 months (range, 6-54 mo). Transplantation restored citrulline metabolism and liver function. Plasma ammonia and citrulline concentration decreased to normal levels with no further hyperammonemic episodes being reported, even after normal diet intake began. Meanwhile, uracil-2 and orotic acid were not detected in urinary excretion. Strikingly, patients suffered developmental retardation before LT showed improved psychomotor ability and significant catch-up growth during the follow-up period. Cognitive ability, including language skills and academic performance, also greatly improved. Three patients had sustained brain injuries and exhibited severe neurological deficits before transplantation, especially repeated generalized tonic-clonic seizures. LT halted neurological deterioration and controlled seizure episodes, which further facilitated the intellectual development and improvement of life quality. CONCLUSIONS LT is an effective treatment for neonatal-onset citrullinemia type I patients, which reverses metabolism decompensation and improves quality of life. For patients who have suffered severe hyperammonemic insults, LT should be conducted at an early age to avoid further neurological or developmental deficits.
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Affiliation(s)
- Yuan Liu
- Department of Liver Surgery, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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18
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Liu F, Bao LS, Liang RJ, Zhao XY, Li Z, Du ZF, Lv SG. Identification of rare variants causing urea cycle disorders: A clinical, genetic, and biophysical study. J Cell Mol Med 2021; 25:4099-4109. [PMID: 33611823 PMCID: PMC8051738 DOI: 10.1111/jcmm.16379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 02/01/2021] [Accepted: 02/04/2021] [Indexed: 12/23/2022] Open
Abstract
Urea cycle disorders (UCDs) are a group of rare metabolic conditions characterized by hyperammonemia and a broad spectrum of phenotypic severity. They are caused by the congenital deficiency in the eight biomolecules involved in urea cycle. In the present study, five cases of UCD were recruited and submitted to a series of clinical, biochemical, and genetic analysis with a combination of high throughput techniques. Moreover, in silico analysis was conducted on the identified missense genetic variants. Various clinical and biochemical indications (including profiles of amino acids and urinary orotic acids) of UCD were manifested by the five probands. Sequence analysis revealed nine diagnostic variants, including three novel ones, which caused Argininosuccinic aciduria (ASA) in one case, Carbamoyl phosphate synthetase 1deficiency (CPS1D) in two cases, Ornithine transcarbamylase deficiency (OTCD) in one case, and Citrin deficiency in 1case. Results of in silico biophysical analysis strongly suggested the pathogenicity of each the five missense variants and provided insight into their intramolecular impacts. In conclusion, this study expanded the genetic variation spectrum of UCD, gave solid evidence for counselling to the affected families, and should facilitate the functional study on the proteins in urea cycle.
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Affiliation(s)
- Fang Liu
- Department of Pediatrics, NICU, Bethune International Peace Hospital (the 980th Hospital of the People's Liberation Army Joint Service Support Force), Shijiazhuang, China
| | - Li-Sha Bao
- Department of Pediatrics, NICU, Bethune International Peace Hospital (the 980th Hospital of the People's Liberation Army Joint Service Support Force), Shijiazhuang, China
| | - Ru-Jia Liang
- Department of Pediatrics, NICU, Bethune International Peace Hospital (the 980th Hospital of the People's Liberation Army Joint Service Support Force), Shijiazhuang, China
| | - Xiao-Ying Zhao
- Department of Pediatrics, NICU, Bethune International Peace Hospital (the 980th Hospital of the People's Liberation Army Joint Service Support Force), Shijiazhuang, China
| | - Zhi Li
- Department of Pediatrics, NICU, Bethune International Peace Hospital (the 980th Hospital of the People's Liberation Army Joint Service Support Force), Shijiazhuang, China
| | - Zhi-Fang Du
- Department of Pediatrics, NICU, Bethune International Peace Hospital (the 980th Hospital of the People's Liberation Army Joint Service Support Force), Shijiazhuang, China
| | - Shao-Guang Lv
- Department of Pediatrics, NICU, Bethune International Peace Hospital (the 980th Hospital of the People's Liberation Army Joint Service Support Force), Shijiazhuang, China
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19
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Posset R, Kölker S, Gleich F, Okun JG, Gropman AL, Nagamani SCS, Scharre S, Probst J, Walter ME, Hoffmann GF, Garbade SF, Zielonka M. Severity-adjusted evaluation of newborn screening on the metabolic disease course in individuals with cytosolic urea cycle disorders. Mol Genet Metab 2020; 131:390-397. [PMID: 33288448 PMCID: PMC8315358 DOI: 10.1016/j.ymgme.2020.10.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/29/2020] [Accepted: 10/31/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The implementation of newborn screening (NBS) programs for citrullinemia type 1 (CTLN1) and argininosuccinic aciduria (ASA) is subject to controversial debate. The aim of this study was to assess the impact of NBS on the metabolic disease course and clinical outcome of affected individuals. METHODS In 115 individuals with CTLN1 and ASA, we compared the severity of the initial hyperammonemic episode (HAE) and the frequency of (subsequent) HAEs with the mode of diagnosis. Based on a recently established functional disease prediction model, individuals were stratified according to their predicted severe or attenuated phenotype. RESULTS Individuals with predicted attenuated forms of CTLN1 and ASA were overrepresented in the NBS group, while those with a predicted severe phenotype were underrepresented compared to individuals identified after the manifestation of symptoms (SX). Identification by NBS was associated with reduced severity of the initial HAE both in individuals with predicted severe and attenuated phenotypes, while it was not associated with lower frequency of (subsequent) HAEs. Similar results were obtained when including some patients diagnosed presymptomatically (i.e. prenatal testing, and high-risk family screening) in this analysis. CONCLUSION Since one of the major challenges of NBS outcome studies is the potential overrepresentation of individuals with predicted attenuated phenotypes in NBS cohorts, severity-adjusted evaluation of screened and unscreened individuals is important to avoid overestimation of the NBS effect. NBS enables the attenuation of the initial HAE but does not affect the frequency of subsequent metabolic decompensations in individuals with CTLN1 and ASA. Future long-term studies will need to evaluate the clinical impact of this finding, especially with regard to mortality, as well as cognitive outcome and quality of life of survivors.
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Affiliation(s)
- Roland Posset
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Stefan Kölker
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Florian Gleich
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Jürgen G Okun
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Andrea L Gropman
- Children's National Health System and The George Washington School of Medicine, Washington, DC, USA
| | - Sandesh C S Nagamani
- Department of Molecular and Human Genetics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Svenja Scharre
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Joris Probst
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Magdalena E Walter
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Georg F Hoffmann
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Sven F Garbade
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Matthias Zielonka
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany; Heidelberg Research Center for Molecular Medicine (HRCMM), Heidelberg, Germany.
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20
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Nitzahn M, Lipshutz GS. CPS1: Looking at an ancient enzyme in a modern light. Mol Genet Metab 2020; 131:289-298. [PMID: 33317798 PMCID: PMC7738762 DOI: 10.1016/j.ymgme.2020.10.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/02/2020] [Accepted: 10/03/2020] [Indexed: 02/06/2023]
Abstract
The mammalian urea cycle (UC) is responsible for siphoning catabolic waste nitrogen into urea for excretion. Disruptions of the functions of any of the enzymes or transporters lead to elevated ammonia and neurological injury. Carbamoyl phosphate synthetase 1 (CPS1) is the first and rate-limiting UC enzyme responsible for the direct incorporation of ammonia into UC intermediates. Symptoms in CPS1 deficiency are typically the most severe of all UC disorders, and current clinical management is insufficient to prevent the associated morbidities and high mortality. With recent advances in basic and translational studies of CPS1, appreciation for this enzyme's essential role in the UC has been broadened to include systemic metabolic regulation during homeostasis and disease. Here, we review recent advances in CPS1 biology and contextualize them around the role of CPS1 in health and disease.
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Affiliation(s)
- Matthew Nitzahn
- Molecular Biology Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA; Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Gerald S Lipshutz
- Molecular Biology Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA; Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA; Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA; Psychiatry, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA; Intellectual and Developmental Disabilities Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA; Semel Institute for Neuroscience, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA.
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21
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Del Re S, Empain A, Vicinanza A, Balasel O, Johansson AB, Stalens JP, De Laet C. Irritability, Poor Feeding and Respiratory Alkalosis in Newborns: Think about Metabolic Emergencies. A Brief Summary of Hyperammonemia Management. Pediatr Rep 2020; 12:77-85. [PMID: 33113778 PMCID: PMC7717652 DOI: 10.3390/pediatric12030019] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 07/27/2020] [Indexed: 12/19/2022] Open
Abstract
The urea cycle is a series of metabolic reactions that convert ammonia into urea in order to eliminate it from the body. Urea cycle disorders are characterized by hyperammonemia, which can cause irreversible damages in central nervous system. We report a series of three newborns presenting irritability, poor feeding and tachypnea. Their first gas analysis revealed respiratory alkalosis. Hyperammonemia was confirmed, and three different enzymatic blocks in the urea cycle were diagnosed. Immediate treatment consisted in the removal of ammonia by reduction of the catabolic state, dietary adjustments, use of nitrogen scavenging agents and ultimately hemodiafiltration. Hyperammonemia is a medical emergency whose treatment should not be delayed. This report aims to highlight the importance of suspecting urea cycle disorders in newborns with aspecific signs of hyperammonemia and respiratory alkalosis, and to sum up the broad lines of hyperammonemia management.
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Affiliation(s)
- Stefano Del Re
- Neonatal Intensive Care Unit, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, 1020 Brussels, Belgium; (O.B.); (A.-B.J.)
- Correspondence: ; Tel.: +32-496-616024
| | - Aurélie Empain
- Department of Nutrition and Metabolism, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, 1020 Brussels, Belgium; (A.E.); (C.D.L.)
| | - Alfredo Vicinanza
- Pediatric Intensive Care Unit, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, 1020 Brussels, Belgium;
| | - Ovidiu Balasel
- Neonatal Intensive Care Unit, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, 1020 Brussels, Belgium; (O.B.); (A.-B.J.)
| | - Anne-Britt Johansson
- Neonatal Intensive Care Unit, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, 1020 Brussels, Belgium; (O.B.); (A.-B.J.)
| | - Jean-Philippe Stalens
- Neonatal Non-Intensive Care Unit, Centre Hospitalier de Wallonie Picarde (Site Union), 7500 Tournai, Belgium;
| | - Corinne De Laet
- Department of Nutrition and Metabolism, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, 1020 Brussels, Belgium; (A.E.); (C.D.L.)
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22
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Considering Proximal Urea Cycle Disorders in Expanded Newborn Screening. Int J Neonatal Screen 2020; 6:ijns6040077. [PMID: 33124615 PMCID: PMC7712149 DOI: 10.3390/ijns6040077] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/20/2020] [Accepted: 09/29/2020] [Indexed: 02/06/2023] Open
Abstract
Proximal urea cycle disorders (PUCDs) have adverse outcomes such as intellectual disability and death, which may benefit from newborn screening (NBS) through early detection and prevention with early treatment. Ornithine transcarbamylase deficiency (OTCD) and carbamoyl phosphate synthetase 1 deficiency (CPS1D) are screened in six and eight states in the United States. We analyzed current evidence to see if it supports inclusion of PUCDs in the NBS panels based upon prevention potential, medical, diagnostic, treatment, and public health rationales. A literature review was performed in PubMed using MESH terms for OTCD, CPS1D, and NAGSD. A systematic review was performed in the hallmark of NBS inclusion criteria. We reviewed 31 articles. Molecular and biochemical diagnosis is available to provide diagnostic evidence. Untreated PUCDs have a significant burden with considerable developmental delay and mortality that may improve with early treatment. Tandem mass spectrometry can be used for NBS for PUCDs; however, citrulline and glutamine alone are not specific. Medical treatments currently available for PUCDs meet existing medical, diagnostic, treatment, and public health rationales. Improvement in NBS algorithms to increase sensitivity and specificity will allow earlier diagnosis and treatment to potentially improve disability and mortality rates.
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23
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Posset R, Garbade SF, Gleich F, Gropman AL, de Lonlay P, Hoffmann GF, Garcia-Cazorla A, Nagamani SCS, Baumgartner MR, Schulze A, Dobbelaere D, Yudkoff M, Kölker S, Zielonka M. Long-term effects of medical management on growth and weight in individuals with urea cycle disorders. Sci Rep 2020; 10:11948. [PMID: 32686765 PMCID: PMC7371674 DOI: 10.1038/s41598-020-67496-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 06/08/2020] [Indexed: 12/18/2022] Open
Abstract
Low protein diet and sodium or glycerol phenylbutyrate, two pillars of recommended long-term therapy of individuals with urea cycle disorders (UCDs), involve the risk of iatrogenic growth failure. Limited evidence-based studies hamper our knowledge on the long-term effects of the proposed medical management in individuals with UCDs. We studied the impact of medical management on growth and weight development in 307 individuals longitudinally followed by the Urea Cycle Disorders Consortium (UCDC) and the European registry and network for Intoxication type Metabolic Diseases (E-IMD). Intrauterine growth of all investigated UCDs and postnatal linear growth of asymptomatic individuals remained unaffected. Symptomatic individuals were at risk of progressive growth retardation independent from the underlying disease and the degree of natural protein restriction. Growth impairment was determined by disease severity and associated with reduced or borderline plasma branched-chain amino acid (BCAA) concentrations. Liver transplantation appeared to have a beneficial effect on growth. Weight development remained unaffected both in asymptomatic and symptomatic individuals. Progressive growth impairment depends on disease severity and plasma BCAA concentrations, but cannot be predicted by the amount of natural protein intake alone. Future clinical trials are necessary to evaluate whether supplementation with BCAAs might improve growth in UCDs.
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Affiliation(s)
- Roland Posset
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Sven F Garbade
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Florian Gleich
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | | | - Pascale de Lonlay
- Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Service de Maladies Metaboliques (MaMEA), filière G2M, Université Paris-Descartes, Paris, France
| | - Georg F Hoffmann
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Angeles Garcia-Cazorla
- Hospital San Joan de Deu, Institut Pediàtric de Recerca. Servicio de Neurologia and CIBERER, ISCIII, Barcelona, Spain
| | - Sandesh C S Nagamani
- Department of Molecular and Human Genetics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Matthias R Baumgartner
- University Children's Hospital Zurich and Children's Research Center, Zurich, Switzerland
| | - Andreas Schulze
- University of Toronto and the Hospital for Sick Children, Toronto, ON, Canada
| | - Dries Dobbelaere
- Centre de Référence Maladies Héréditaires du Métabolisme de L'Enfant Et de L'Adulte, Jeanne de Flandre Hospital, CHRU Lille, and Faculty of Medicine, University Lille 2, Lille, France
| | - Marc Yudkoff
- School of Medicine and Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Stefan Kölker
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Matthias Zielonka
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany.
- Heidelberg Research Center for Molecular Medicine (HRCMM), Heidelberg, Germany.
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24
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Sugiyama Y, Shimura M, Ogawa-Tominaga M, Ebihara T, Kinouchi Y, Isozaki K, Matsuhashi T, Tajika M, Fushimi T, Ichimoto K, Matsunaga A, Ishida T, Mizutani K, Tsuruoka T, Murayama K. Therapeutic effect of N-carbamylglutamate in CPS1 deficiency. Mol Genet Metab Rep 2020; 24:100622. [PMID: 32670798 PMCID: PMC7347628 DOI: 10.1016/j.ymgmr.2020.100622] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/24/2020] [Accepted: 06/24/2020] [Indexed: 12/12/2022] Open
Abstract
The detoxification of ammonia to urea requires a functional hepatic urea cycle, which consists of six enzymes and two mitochondrial membrane transporters. The initial step of the urea cycle is catalyzed by carbamyl phosphate synthetase 1 (CPS1). CPS1 deficiency (CPS1D) is a rare autosomal recessive disorder. N-Carbamylglutamate (NCG), a deacylase-resistant analogue of N-acetylglutamate, can activate CPS1. We describe the therapeutic course of a patient suffering from neonatal onset CPS1D with compound heterozygosity for the c.2359C > T (p.Arg787*) and c.3559G > T (p.Val1187Phe) variants in CPS1, treated with NCG. She presented with hyperammonemia, which reached 944 μmol/L at the age of 2 days. The ammonia concentration decreased after treatment with continuous hemodiafiltration, NCG, sodium benzoate, sodium phenylbutyrate, L-arginine, vitamin cocktail (vitamin B1, vitamin B12, vitamin C, vitamin E, biotin), l-carnitine, coenzyme Q10, and parenteral nutrition. Her ammonia and glutamine levels remained low; thus, protein intake was increased to 1.2 g/kg/day. Furthermore, the amount of sodium benzoate and sodium phenylbutyrate were reduced. She remained metabolically stable and experienced no metabolic crisis following treatment with oral NCG, sodium benzoate, sodium phenylbutyrate, citrulline, vitamin cocktail, l-carnitine, and coenzyme Q10 until she underwent liver transplantation at 207 days of age. She had no neurological complications at the age of 15 months. Ammonia and glutamine levels of the patient were successfully maintained at a low level via NCG treatment with increased protein intake, which led to normal neurological development. Thus, undiagnosed urea cycle disorders should be treated rapidly with acute therapy including NCG, which should be maintained until a genetic diagnosis is reached. It is essential to prevent metabolic crises in patients with CPS1D until liver transplantation to improve their prognoses.
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Affiliation(s)
- Yohei Sugiyama
- Center for Medical Genetics, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan
- Department of Metabolism, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan
- Department of Neonatology, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan
| | - Masaru Shimura
- Center for Medical Genetics, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan
- Department of Metabolism, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan
| | - Minako Ogawa-Tominaga
- Department of Metabolism, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan
| | - Tomohiro Ebihara
- Center for Medical Genetics, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan
- Department of Neonatology, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan
| | - Yoshina Kinouchi
- Center for Medical Genetics, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan
- Department of Neonatology, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan
| | - Keitaro Isozaki
- Center for Medical Genetics, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan
- Department of Neonatology, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan
| | - Tetsuro Matsuhashi
- Center for Medical Genetics, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan
- Department of Metabolism, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan
| | - Makiko Tajika
- Center for Medical Genetics, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan
- Department of Metabolism, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan
| | - Takuya Fushimi
- Center for Medical Genetics, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan
- Department of Metabolism, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan
| | - Keiko Ichimoto
- Center for Medical Genetics, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan
- Department of Metabolism, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan
| | - Ayako Matsunaga
- Center for Medical Genetics, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan
- Department of Metabolism, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan
| | - Tomoki Ishida
- Department of Neonatology, Kimitsu Chuo Hospital, 1010 sakurai, Kisarazu city, Chiba 292-8535, Japan
| | - Kayo Mizutani
- Department of Neonatology, Kameda Medical Center, 929 Higashi-cho, Kamogawa City, Chiba 296-8602, Japan
| | - Tomoko Tsuruoka
- Center for Medical Genetics, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan
- Department of Neonatology, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan
| | - Kei Murayama
- Center for Medical Genetics, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan
- Department of Metabolism, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan
- Corresponding author at: Center for Medical Genetics, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba city, Chiba 266-0007, Japan.
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25
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Pontoizeau C, Roda C, Arnoux JB, Vignolo-Diard P, Brassier A, Habarou F, Barbier V, Grisel C, Abi-Warde MT, Boddaert N, Kuster A, Servais A, Kaminska A, Hennequin C, Dupic L, Lesage F, Touati G, Valayannopoulos V, Chadefaux-Vekemans B, Oualha M, Eisermann M, Ottolenghi C, de Lonlay P. Neonatal factors related to survival and intellectual and developmental outcome of patients with early-onset urea cycle disorders. Mol Genet Metab 2020; 130:110-117. [PMID: 32273051 DOI: 10.1016/j.ymgme.2020.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 03/14/2020] [Accepted: 03/14/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE We aimed to identify prognostic factors for survival and long-term intellectual and developmental outcome in neonatal patients with early-onset urea cycle disorders (UCD) experiencing hyperammonaemic coma. METHODS We retrospectively analysed ammonia (NH3) and glutamine levels, electroencephalogram and brain images obtained during neonatal coma of UCD patients born between 1995 and 2011 and managed at a single centre and correlated them to survival and intellectual and developmental outcome. RESULTS We included 38 neonates suffering from deficiencies of argininosuccinate synthetase (ASSD, N = 12), ornithine transcarbamylase (OTCD, N = 10), carbamoylphosphate synthetase 1 (CPSD, N = 7), argininosuccinate lyase (ASLD, N = 7), N-acetylglutamate synthase (NAGS, N = 1) or arginase (ARGD, N = 1). Symptoms occurred earlier in mitochondrial than in cytosolic UCD. Sixty-eight percent of patients survived, with a mean (standard deviation-SD) follow-up of 10.4 (5.3) years. Mortality was mostly observed in OTCD (N = 7/10) and CPSD (N = 4/7) patients. Plasma NH3 level during the neonatal period, expressed as area under the curve, but not glutamine level was associated with mortality (p = .044 and p = .610). 62.1% of the patients had normal intellectual and developmental outcome. Intellectual and developmental outcome tended to correlate with UCD subtype (p = .052). No difference in plasma NH3 or glutamine level during the neonatal period among developmental outcomes was identified. EEG severity was linked to UCD subtypes (p = .004), ammonia levels (p = .037), duration of coma (p = .043), and mortality during the neonatal period (p = .020). Status epilepticus was recorded in 6 patients, 3 of whom died neonatally, 1 developed a severe intellectual disability while the 2 last patients had a normal development. CONCLUSION UCD subtypes differed by survival rate, intellectual and developmental outcome and EEG features in the neonatal period. Hyperammonaemia expressed as area under the curve was associated with survival but not with intellectual and developmental outcome whereas glutamine was not associated with one of these outcomes. Prognostic value of video-EEG monitoring and the association between status epilepticus and mortality should be assessed in neonatal hyperammonaemic coma in further studies.
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Affiliation(s)
- Clément Pontoizeau
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France; Metabolomics Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France.
| | - Célina Roda
- Université de Paris, CRESS, INSERM, INRA, HERA team (Health Environmental Risk Assessment), F-75004 Paris, France
| | - Jean-Baptiste Arnoux
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | | | - Anais Brassier
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Florence Habarou
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France; Metabolomics Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Valérie Barbier
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Coraline Grisel
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Marie-Thérèse Abi-Warde
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Nathalie Boddaert
- Department of Pediatric Radiology, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, PRES Sorbonne Paris Cité, INSERM U1000, Institut Imagine, Paris, France
| | - Alice Kuster
- Pediatric Critical Care Unit, Femme-Enfants-Adolescents Hospital, Nantes University, Nantes, France
| | - Aude Servais
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France; Department of Nephrology, Transplantation, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Anna Kaminska
- Neurophysiology Unit, AP-HP, Necker Enfants Malades Hospital, Paris, France
| | - Carole Hennequin
- Biochemistry, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Laurent Dupic
- Pediatric Critical Care Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Fabrice Lesage
- Pediatric Critical Care Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Guy Touati
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Vassili Valayannopoulos
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Bernadette Chadefaux-Vekemans
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France; Metabolomics Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Mehdi Oualha
- Pediatric Critical Care Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Monika Eisermann
- Neurophysiology Unit, AP-HP, Necker Enfants Malades Hospital, Paris, France
| | - Chris Ottolenghi
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France; Metabolomics Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Pascale de Lonlay
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
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Probst J, Kölker S, Okun JG, Kumar A, Gursky E, Posset R, Hoffmann GF, Peravali R, Zielonka M. Chronic hyperammonemia causes a hypoglutamatergic and hyperGABAergic metabolic state associated with neurobehavioral abnormalities in zebrafish larvae. Exp Neurol 2020; 331:113330. [PMID: 32339612 DOI: 10.1016/j.expneurol.2020.113330] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/29/2020] [Accepted: 04/23/2020] [Indexed: 12/13/2022]
Abstract
Chronic hyperammonemia is a common condition affecting individuals with inherited urea cycle disorders resulting in progressive cognitive impairment and behavioral abnormalities. Altered neurotransmission has been proposed as major source of neuronal dysfunction during chronic hyperammonemia, but the molecular pathomechanism has remained incompletely understood. Here we show that chronic exposure to ammonium acetate induces locomotor dysfunction and abnormal feeding behavior in zebrafish larvae, indicative for an impairment of higher brain functions. Biochemically, chronically elevated ammonium concentrations cause enhanced activity of glutamate decarboxylase isoforms GAD1 and GAD2 with increased formation of GABA and concomitant depletion of glutamate, ultimately leading to a dysfunctional hypoglutamatergic and hyperGABAergic metabolic state. Moreover, elevated GABA concentrations are accompanied by increased expression of GABAA receptor subunits alpha-1, gamma-2 and delta, supporting the notion of an increased GABA tone in chronic hyperammonemia. Propionate oxidation as major anaplerotic reaction sufficiently compensates for the transamination-dependent withdrawal of 2-oxoglutarate, thereby preventing bioenergetic dysfunction under chronic hyperammonemic conditions. Thus, our study extends the hypothesis of alterations in the glutamatergic and GABAergic system being an important pathophysiological factor causing neurobehavioral impairment in chronic hyperammonemia. Given that zebrafish larvae have already been successfully used for high-throughput identification of novel compounds to treat inherited neurological diseases, the reported zebrafish model should be considered an important tool for systematic drug screening targeting altered glutamatergic and GABAergic metabolism under chronic hyperammonemic conditions in the future.
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Affiliation(s)
- Joris Probst
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Kölker
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Jürgen G Okun
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Amrish Kumar
- Institute of Toxicology and Genetics (ITG), Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
| | - Eduard Gursky
- Institute of Toxicology and Genetics (ITG), Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
| | - Roland Posset
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Georg F Hoffmann
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Ravindra Peravali
- Institute of Toxicology and Genetics (ITG), Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
| | - Matthias Zielonka
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Research Center for Molecular Medicine (HRCMM), Heidelberg, Germany.
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Nitzahn M, Allegri G, Khoja S, Truong B, Makris G, Häberle J, Lipshutz GS. Split AAV-Mediated Gene Therapy Restores Ureagenesis in a Murine Model of Carbamoyl Phosphate Synthetase 1 Deficiency. Mol Ther 2020; 28:1717-1730. [PMID: 32359471 DOI: 10.1016/j.ymthe.2020.04.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 02/25/2020] [Accepted: 04/09/2020] [Indexed: 02/07/2023] Open
Abstract
The urea cycle enzyme carbamoyl phosphate synthetase 1 (CPS1) catalyzes the initial step of the urea cycle; bi-allelic mutations typically present with hyperammonemia, vomiting, ataxia, lethargy progressing into coma, and death due to brain edema if ineffectively treated. The enzyme deficiency is particularly difficult to treat; early recognition is essential to minimize injury to the brain. Even under optimal conditions, therapeutic interventions are of limited scope and efficacy, with most patients developing long-term neurologic sequelae. One significant encumberment to gene therapeutic development is the size of the CPS1 cDNA, which, at 4.5 kb, nears the packaging capacity of adeno-associated virus (AAV). Herein we developed a split AAV (sAAV)-based approach, packaging the large transgene and its regulatory cassette into two separate vectors, thereby delivering therapeutic CPS1 by a dual vector system with testing in a murine model of the disorder. Cps1-deficient mice treated with sAAVs survive long-term with markedly improved ammonia levels, diminished dysregulation of circulating amino acids, and increased hepatic CPS1 expression and activity. In response to acute ammonia challenging, sAAV-treated female mice rapidly incorporated nitrogen into urea. This study demonstrates the first proof-of-principle that sAAV-mediated therapy is a viable, potentially clinically translatable approach to CPS1 deficiency, a devastating urea cycle disorder.
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Affiliation(s)
- Matthew Nitzahn
- Molecular Biology Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA; Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Gabriella Allegri
- Division of Metabolism and Children's Research Center, University Children's Hospital, Zurich, Switzerland
| | - Suhail Khoja
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Brian Truong
- Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Georgios Makris
- 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
| | - Gerald S Lipshutz
- Molecular Biology Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA; Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA; Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA; Department of Psychiatry, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA; Intellectual and Developmental Disabilities Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA; Semel Institute for Neuroscience, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA.
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28
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Häberle J, Burlina A, Chakrapani A, Dixon M, Karall D, Lindner M, Mandel H, Martinelli D, Pintos-Morell G, Santer R, Skouma A, Servais A, Tal G, Rubio V, Huemer M, Dionisi-Vici C. Suggested guidelines for the diagnosis and management of urea cycle disorders: First revision. J Inherit Metab Dis 2019; 42:1192-1230. [PMID: 30982989 DOI: 10.1002/jimd.12100] [Citation(s) in RCA: 236] [Impact Index Per Article: 47.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 04/04/2019] [Accepted: 04/08/2019] [Indexed: 02/06/2023]
Abstract
In 2012, we published guidelines summarizing and evaluating late 2011 evidence for diagnosis and therapy of urea cycle disorders (UCDs). With 1:35 000 estimated incidence, UCDs cause hyperammonemia of neonatal (~50%) or late onset that can lead to intellectual disability or death, even while effective therapies do exist. In the 7 years that have elapsed since the first guideline was published, abundant novel information has accumulated, experience on newborn screening for some UCDs has widened, a novel hyperammonemia-causing genetic disorder has been reported, glycerol phenylbutyrate has been introduced as a treatment, and novel promising therapeutic avenues (including gene therapy) have been opened. Several factors including the impact of the first edition of these guidelines (frequently read and quoted) may have increased awareness among health professionals and patient families. However, under-recognition and delayed diagnosis of UCDs still appear widespread. It was therefore necessary to revise the original guidelines to ensure an up-to-date frame of reference for professionals and patients as well as for awareness campaigns. This was accomplished by keeping the original spirit of providing a trans-European consensus based on robust evidence (scored with GRADE methodology), involving professionals on UCDs from nine countries in preparing this consensus. We believe this revised guideline, which has been reviewed by several societies that are involved in the management of UCDs, will have a positive impact on the outcomes of patients by establishing common standards, and spreading and harmonizing good practices. It may also promote the identification of knowledge voids to be filled by future research.
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Affiliation(s)
- Johannes Häberle
- University Children's Hospital Zurich and Children's Research Centre, Zurich, Switzerland
| | - Alberto Burlina
- Division of Inborn Metabolic Disease, Department of Pediatrics, University Hospital Padua, Padova, Italy
| | - Anupam Chakrapani
- Department of Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Marjorie Dixon
- Dietetics, Great Ormond Street Hospital for Children, NHS Trust, London, UK
| | - Daniela Karall
- Clinic for Pediatrics, Division of Inherited Metabolic Disorders, Medical University of Innsbruck, Innsbruck, Austria
| | - Martin Lindner
- University Children's Hospital, Frankfurt am Main, Germany
| | - Hanna Mandel
- Institute of Human Genetics and metabolic disorders, Western Galilee Medical Center, Nahariya, Israel
| | - Diego Martinelli
- Division of Metabolism, Bambino Gesù Children's Hospital, Rome, Italy
| | - Guillem Pintos-Morell
- Centre for Rare Diseases, University Hospital Vall d'Hebron, Barcelona, Spain
- CIBERER_GCV08, Research Institute IGTP, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - René Santer
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anastasia Skouma
- Institute of Child Health, Agia Sofia Children's Hospital, Athens, Greece
| | - Aude Servais
- Service de Néphrologie et maladies métaboliques adulte Hôpital Necker 149, Paris, France
| | - Galit Tal
- The Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Vicente Rubio
- Instituto de Biomedicina de Valencia (IBV-CSIC), Centro de Investigación Biomédica en Red para Enfermedades Raras (CIBERER), Valencia, Spain
| | - Martina Huemer
- University Children's Hospital Zurich and Children's Research Centre, Zurich, Switzerland
- Department of Paediatrics, Landeskrankenhaus Bregenz, Bregenz, Austria
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29
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Zielonka M, Kölker S, Gleich F, Stützenberger N, Nagamani SCS, Gropman AL, Hoffmann GF, Garbade SF, Posset R. Early prediction of phenotypic severity in Citrullinemia Type 1. Ann Clin Transl Neurol 2019; 6:1858-1871. [PMID: 31469252 PMCID: PMC6764635 DOI: 10.1002/acn3.50886] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 08/14/2019] [Indexed: 12/31/2022] Open
Abstract
Objective Citrullinemia type 1 (CTLN1) is an inherited metabolic disease affecting the brain which is detectable by newborn screening. The clinical spectrum is highly variable including individuals with lethal hyperammonemic encephalopathy in the newborn period and individuals with a mild‐to‐moderate or asymptomatic disease course. Since the phenotypic severity has not been predictable early during the disease course so far, we aimed to design a reliable disease prediction model. Methods We used a newly established mammalian biallelic expression system to determine residual enzymatic activity of argininosuccinate synthetase 1 (ASS1; OMIM #215700) in 71 individuals with CTLN1, representing 48 ASS1 gene variants and 50 different, mostly compound heterozygous combinations in total. Residual enzymatic ASS1 activity was correlated to standardized biochemical and clinical endpoints available from the UCDC and E‐IMD databases. Results Residual enzymatic ASS1 activity correlates with peak plasma ammonium and L‐citrulline concentrations at initial presentation. Individuals with 8% of residual enzymatic ASS1 activity or less had more frequent and more severe hyperammonemic events and lower cognitive function than those above 8%, highlighting that residual enzymatic ASS1 activity allows reliable severity prediction. Noteworthy, empiric clinical practice of affected individuals is in line with the predicted disease severity supporting the notion of a risk stratification‐based guidance of therapeutic decision‐making based on residual enzymatic ASS1 activity in the future. Interpretation Residual enzymatic ASS1 activity reliably predicts the phenotypic severity in CTLN1. We propose a new severity‐adjusted classification system for individuals with CTLN1 based on the activity results of the newly established biallelic expression system.
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Affiliation(s)
- Matthias Zielonka
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany.,Heidelberg Research Center for Molecular Medicine (HRCMM), Heidelberg, Germany
| | - Stefan Kölker
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Florian Gleich
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Nicolas Stützenberger
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Sandesh C S Nagamani
- Department of Molecular and Human Genetics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Andrea L Gropman
- Children's National Health System, The George Washington School of Medicine, District of Columbia, Washington
| | - Georg F Hoffmann
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Sven F Garbade
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Roland Posset
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
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30
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Lin Y, Zheng Q, Zheng T, Zheng Z, Lin W, Fu Q. Expanded newborn screening for inherited metabolic disorders and genetic characteristics in a southern Chinese population. Clin Chim Acta 2019; 494:106-111. [DOI: 10.1016/j.cca.2019.03.1622] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 03/20/2019] [Indexed: 12/30/2022]
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31
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Posset R, Gropman AL, Nagamani SCS, Burrage LC, Bedoyan JK, Wong D, Berry GT, Baumgartner MR, Yudkoff M, Zielonka M, Hoffmann GF, Burgard P, Schulze A, McCandless SE, Garcia-Cazorla A, Seminara J, Garbade SF, Kölker S. Impact of Diagnosis and Therapy on Cognitive Function in Urea Cycle Disorders. Ann Neurol 2019; 86:116-128. [PMID: 31018246 DOI: 10.1002/ana.25492] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 04/02/2019] [Accepted: 04/21/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Individuals with urea cycle disorders (UCDs) often present with intellectual and developmental disabilities. The major aim of this study was to evaluate the impact of diagnostic and therapeutic interventions on cognitive outcomes in UCDs. METHODS This prospective, observational, multicenter study includes data from 503 individuals with UCDs who had comprehensive neurocognitive testing with a cumulative follow-up of 702 patient-years. RESULTS The mean cognitive standard deviation score (cSDS) was lower in symptomatic than in asymptomatic (p < 0.001, t test) individuals with UCDs. Intellectual disability (intellectual quotient < 70, cSDS < -2.0) was associated with the respective subtype of UCD and early disease onset, whereas height of the initial peak plasma ammonium concentration was inversely associated with neurocognitive outcomes in mitochondrial (proximal) rather than cytosolic (distal) UCDs. In ornithine transcarbamylase and argininosuccinate synthetase 1 deficiencies, we did not find evidence that monoscavenger therapy with sodium or glycerol phenylbutyrate was superior to sodium benzoate in providing cognitive protection. Early liver transplantation appears to be beneficial for UCDs. It is noteworthy that individuals with argininosuccinate synthetase 1 and argininosuccinate lyase deficiencies identified by newborn screening had better neurocognitive outcomes than those diagnosed after the manifestation of first symptoms. INTERPRETATION Cognitive function is related to interventional and non-interventional variables. Early detection by newborn screening and early liver transplantation appear to offer greater cognitive protection, but none of the currently used nitrogen scavengers was superior with regard to long-term neurocognitive outcome. Further confirmation could determine these variables as important clinical indicators of neuroprotection for individuals with UCDs. ANN NEUROL 2019.
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Affiliation(s)
- Roland Posset
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Andrea L Gropman
- Children's National Health System and George Washington School of Medicine, Washington, DC
| | - Sandesh C S Nagamani
- Department of Molecular and Human Genetics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Lindsay C Burrage
- Department of Molecular and Human Genetics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Jirair K Bedoyan
- Center for Human Genetics and Department of Genetics and Genome Sciences, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, OH
| | - Derek Wong
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA
| | - Gerard T Berry
- Harvard Medical School and Boston Children's Hospital, Boston, MA
| | - Matthias R Baumgartner
- University Children's Hospital Zurich and Children's Research Center, Zurich, Switzerland
| | - Marc Yudkoff
- University of Pennsylvania School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA
| | - Matthias Zielonka
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany.,Heidelberg Research Center for Molecular Medicine, Heidelberg, Germany
| | - Georg F Hoffmann
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter Burgard
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Andreas Schulze
- Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Shawn E McCandless
- Children's Hospital Colorado and University of Colorado, School of Medicine, Aurora, CO
| | - Angeles Garcia-Cazorla
- Hospital San Joan de Deu, Institut Pediàtric de Recerca. Servicio de Neurologia and CIBERER, ISCIII, Barcelona, Spain
| | - Jennifer Seminara
- Children's National Health System and George Washington School of Medicine, Washington, DC
| | - Sven F Garbade
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Kölker
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
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32
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Teufel U, Burgard P, Meyburg J, Lindner M, Poeschl J, Ruef P, Hoffmann GF, Kölker S. High blood pressure, a red flag for the neonatal manifestation of urea cycle disorders. Orphanet J Rare Dis 2019; 14:80. [PMID: 30961665 PMCID: PMC6454767 DOI: 10.1186/s13023-019-1055-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 04/01/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Neonatal manifestation of life-threatening hyperammonemic encephalopathy in urea cycle disorders (UCD) is often misdiagnosed as neonatal sepsis, resulting in significantly delayed start of specific treatment and poor outcome. The major aim of this study was to identify specific initial symptoms or signs to clinically distinguish hyperammonemic encephalopathy in neonates from neonatal sepsis in order to identify affected individuals with UCD and to start metabolic therapy without delay. Furthermore, we evaluated the impact of diagnostic delay, peak plasma ammonium (NH4+) concentration, mode of emergency treatment and transfer to a tertiary referral center on the outcome. METHODS Detailed information of 17 patients (born between 1994 and 2012) with confirmed diagnosis of UCD and neonatal hyperammonemic encephalopathy were collected from the original medical records. RESULTS The initially suspected diagnosis was neonatal sepsis in all patients, but was not confirmed in any of them. Unlike neonatal sepsis and not previously reported blood pressure increased above the 95th percentile in 13 (81%) of UCD patients before emergency treatment was started. Respiratory alkalosis was found in 11 (65%) of UCD patients, and in 14 (81%) plasma NH4+concentrations further increased despite initiation of metabolic therapy. CONCLUSION Detection of high blood pressure could be a valuable parameter for distinguishing neonatal sepsis from neonatal manifestation of UCD. Since high blood pressure is not typical for neonatal sepsis, other reasons such as encephalopathy and especially hyperammonemic encephalopathy (caused by e.g. UCD) should be searched for immediately. However, our result that the majority of newborns with UCD initially present with high blood pressure has to be evaluated in larger patient cohorts.
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Affiliation(s)
- Ulrike Teufel
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany. .,Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Peter Burgard
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Jochen Meyburg
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Lindner
- University Children's Hospital Frankfurt, Frankfurt, Germany
| | - Johannes Poeschl
- Department of Pediatrics, Clinic of Neonatology, University of Heidelberg, Heidelberg, Germany
| | - Peter Ruef
- Department of Pediatrics, SLK-Kliniken Heilbronn GmbH, Heilbronn, Germany
| | - Georg F Hoffmann
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Kölker
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
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Zielonka M, Probst J, Carl M, Hoffmann GF, Kölker S, Okun JG. Bioenergetic dysfunction in a zebrafish model of acute hyperammonemic decompensation. Exp Neurol 2019; 314:91-99. [PMID: 30653968 DOI: 10.1016/j.expneurol.2019.01.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 12/18/2018] [Accepted: 01/12/2019] [Indexed: 12/30/2022]
Abstract
Acute hyperammonemic encephalopathy is a life-threatening manifestation of individuals with urea cycle disorders, which is associated with high mortality rates and severe neurological sequelae in survivors. Cerebral bioenergetic failure has been proposed as one of the key mechanisms underlying hyperammonemia-induced brain damage, but data supporting this hypothesis remain inconclusive and partially contradictory. Using a previously established zebrafish model of acute hyperammonemic decompensation, we unraveled that acute hyperammonemia leads to a transamination-dependent withdrawal of 2-oxoglutarate (alpha-ketoglutarate) from the tricarboxylic acid (TCA) cycle with consecutive TCA cycle dysfunction, ultimately causing impaired oxidative phosphorylation with ATP shortage, decreased ATP/ADP-ratio and elevated lactate concentrations. Thus, our study supports and extends the hypothesis that cerebral bioenergetic dysfunction is an important pathophysiological hallmark of hyperammonemia-induced neurotoxicity.
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Affiliation(s)
- Matthias Zielonka
- Center for Child and Adolescent Medicine, Division for Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Research Center for Molecular Medicine (HRCMM), Heidelberg, Germany.
| | - Joris Probst
- Center for Child and Adolescent Medicine, Division for Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Carl
- Center for Integrative Biology (CIBIO), Laboratory of Translational Neurogenetics, University of Trento, Trento, Italy
| | - Georg Friedrich Hoffmann
- Center for Child and Adolescent Medicine, Division for Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Kölker
- Center for Child and Adolescent Medicine, Division for Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Jürgen Günther Okun
- Center for Child and Adolescent Medicine, Division for Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
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Posset R, Garbade SF, Boy N, Burlina AB, Dionisi-Vici C, Dobbelaere D, Garcia-Cazorla A, de Lonlay P, Teles EL, Vara R, Mew NA, Batshaw ML, Baumgartner MR, McCandless S, Seminara J, Summar M, Hoffmann GF, Kölker S, Burgard P. Transatlantic combined and comparative data analysis of 1095 patients with urea cycle disorders-A successful strategy for clinical research of rare diseases. J Inherit Metab Dis 2019; 42:93-106. [PMID: 30740724 PMCID: PMC7329920 DOI: 10.1002/jimd.12031] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND To improve our understanding of urea cycle disorders (UCDs) prospectively followed by two North American (NA) and European (EU) patient cohorts. AIMS Description of the NA and EU patient samples and investigation of the prospects of combined and comparative analyses for individuals with UCDs. METHODS Retrieval and comparison of the data from 1095 individuals (NA: 620, EU: 475) from two electronic databases. RESULTS The proportion of females with ornithine transcarbamylase deficiency (fOTC-D), particularly those being asymptomatic (asfOTC-D), was higher in the NA than in the EU sample. Exclusion of asfOTC-D resulted in similar distributions in both samples. The mean age at first symptoms was higher in NA than in EU patients with late onset (LO), but similar for those with early (≤ 28 days) onset (EO) of symptoms. Also, the mean age at diagnosis and diagnostic delay for EO and LO patients were similar in the NA and EU cohorts. In most patients (including fOTC-D), diagnosis was made after the onset of symptoms (59.9%) or by high-risk family screening (24.7%), and less often by newborn screening (8.9%) and prenatal testing (3.7%). Analysis of clinical phenotypes revealed that EO patients presented with more symptoms than LO individuals, but that numbers of symptoms correlated with plasma ammonium concentrations in EO patients only. Liver transplantation was reported for 90 NA and 25 EU patients. CONCLUSIONS Combined analysis of databases drawn from distinct populations opens the possibility to increase sample sizes for natural history questions, while comparative analysis utilizing differences in approach to treatment can evaluate therapeutic options and enhance long-term outcome studies.
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Affiliation(s)
- Roland Posset
- Centre for Pediatric and Adolescent Medicine, Division of Neuropediatrics and Inherited Metabolic Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Sven F. Garbade
- Centre for Pediatric and Adolescent Medicine, Division of Neuropediatrics and Inherited Metabolic Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Nikolas Boy
- Centre for Pediatric and Adolescent Medicine, Division of Neuropediatrics and Inherited Metabolic Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Alberto B. Burlina
- Azienda Ospedaliera di Padova, U.O.C. Malattie Metaboliche Ereditarie, Padova, Italy
| | - Carlo Dionisi-Vici
- Ospedale Pediatrico Bambino Gésu, U.O.C. Patologia Metabolica, Rome, Italy
| | - Dries Dobbelaere
- Centre de Référence Maladies Héréditaires du Métabolisme de l’Enfant et de l’Adulte, Jeanne de Flandre Hospital, CHRU Lille, and RADEME EA 7364, Faculty of Medicine, University Lille 2, Lille 59037, France
| | - Angeles Garcia-Cazorla
- Hospital San Joan de Deu, Institut Pediàtric de Recerca. Servicio de Neurologia and CIBERER, ISCIII, Barcelona, Spain
| | - Pascale de Lonlay
- Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Service de Maladies Métaboliques, Paris, France
| | - Elisa Leão Teles
- Unidade de Doenças Metabólicas, Serviço de Pediatria, Hospital de S. João, EPE, Porto, Portugal
| | - Roshni Vara
- Evelina Children’s Hospital, St Thomas’ Hospital, London, UK
| | - Nicholas Ah Mew
- Children’s National Health System and The George Washington School of Medicine, Washington, District of Columbia, USA
| | - Mark L. Batshaw
- Children’s National Health System and The George Washington School of Medicine, Washington, District of Columbia, USA
| | | | - Shawn McCandless
- Case Western Reserve University and University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Jennifer Seminara
- Children’s National Health System and The George Washington School of Medicine, Washington, District of Columbia, USA
| | - Marshall Summar
- Rare Disease Institute, Children’s National Health System, 111 Michigan Ave., NW, Washington, DC, 20010, USA
| | - Georg F. Hoffmann
- Centre for Pediatric and Adolescent Medicine, Division of Neuropediatrics and Inherited Metabolic Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Stefan Kölker
- Centre for Pediatric and Adolescent Medicine, Division of Neuropediatrics and Inherited Metabolic Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Peter Burgard
- Centre for Pediatric and Adolescent Medicine, Division of Neuropediatrics and Inherited Metabolic Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
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Bijarnia-Mahay S, Häberle J, Jalan AB, Puri RD, Kohli S, Kudalkar K, Rüfenacht V, Gupta D, Maurya D, Verma J, Shigematsu Y, Yamaguchi S, Saxena R, Verma IC. Urea cycle disorders in India: clinical course, biochemical and genetic investigations, and prenatal testing. Orphanet J Rare Dis 2018; 13:174. [PMID: 30285816 PMCID: PMC6167905 DOI: 10.1186/s13023-018-0908-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 09/12/2018] [Indexed: 02/07/2023] Open
Abstract
Background Urea cycle disorders (UCDs) are inherited metabolic disorders that present with hyperammonemia, and cause significant mortality and morbidity in infants and children. These disorders are not well reported in the Indian population, due to lack of a thorough study of the clinical and molecular profile. Results We present data from two major metabolic centres in India, including 123 cases of various UCDs. The majority of them (72/123, 58%) presented in the neonatal period (before 30 days of age) with 88% on or before day 7 of life (classical presentation), and had a high mortality (64/72, 88%). Citrullinemia type 1 was the most common UCD, observed in 61/123 patients. Ornithine transcarbamylase (OTC) deficiency was the next most common, seen in 24 cases. Argininosuccinic aciduria was diagnosed in 20 cases. Deficiencies of arginase, N-acetylglutamate synthase, carbamoyl phosphate synthetase, citrin, and lysinuric protein intolerance were also observed. Molecular genetic analysis revealed two common ASS1 mutations: c.470G > A (p.Arg157His) and c.1168G > A (p.Gly390Arg) (36 of 55 tested patients). In addition, few recurrent point mutations in ASL gene, and a deletion of the whole OTC gene were also noted. A total of 24 novel mutations were observed in the various genes studied. We observed a poor clinical outcome with an overall all time mortality of 63% (70/110 cases with a known follow-up), and disability in 70% (28/40) among the survivors. Prenatal diagnosis was performed in 30 pregnancies in 25 families, including one pre-implantation genetic diagnosis. Conclusions We report the occurrence of UCDs in India and the spectrum that may be different from the rest of the world. Citrullinemia type 1 was the most common UCD observed in the cohort. Increasing awareness amongst clinicians will improve outcomes through early diagnosis and timely treatment. Genetic diagnosis in the proband will enable prenatal/pre-implantation diagnosis in subsequent pregnancies. Electronic supplementary material The online version of this article (10.1186/s13023-018-0908-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sunita Bijarnia-Mahay
- Institute of Medical Genetics and Genomics, Sir Ganga Ram Hospital, New Delhi, India.
| | - Johannes Häberle
- University Children's Hospital Zurich and Children's Research Centre, Steinwiesstr 75, CH-8032, Zurich, Switzerland
| | - Anil B Jalan
- Navi Mumbai Institute of Research In Mental And Neurological Handicap (NIRMAN), Navi Mumbai, India
| | - Ratna Dua Puri
- Institute of Medical Genetics and Genomics, Sir Ganga Ram Hospital, New Delhi, India
| | - Sudha Kohli
- Institute of Medical Genetics and Genomics, Sir Ganga Ram Hospital, New Delhi, India
| | - Ketki Kudalkar
- Navi Mumbai Institute of Research In Mental And Neurological Handicap (NIRMAN), Navi Mumbai, India
| | - Véronique Rüfenacht
- University Children's Hospital Zurich and Children's Research Centre, Steinwiesstr 75, CH-8032, Zurich, Switzerland
| | - Deepti Gupta
- Institute of Medical Genetics and Genomics, Sir Ganga Ram Hospital, New Delhi, India
| | - Deepshikha Maurya
- Institute of Medical Genetics and Genomics, Sir Ganga Ram Hospital, New Delhi, India
| | - Jyotsna Verma
- Institute of Medical Genetics and Genomics, Sir Ganga Ram Hospital, New Delhi, India
| | - Yosuke Shigematsu
- Department of Pediatrics, Faculty of Medical Science, University of Fukui, Fukui, Japan
| | - Seiji Yamaguchi
- Department of Pediatrics, Shimane University Faculty of Medicine, 89-1 En-ya-cho Izumo, Shimane, 693-8501, Japan
| | - Renu Saxena
- Institute of Medical Genetics and Genomics, Sir Ganga Ram Hospital, New Delhi, India
| | - Ishwar C Verma
- Institute of Medical Genetics and Genomics, Sir Ganga Ram Hospital, New Delhi, India
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Zielonka M, Breuer M, Okun JG, Carl M, Hoffmann GF, Kölker S. Pharmacologic rescue of hyperammonemia-induced toxicity in zebrafish by inhibition of ornithine aminotransferase. PLoS One 2018; 13:e0203707. [PMID: 30199544 PMCID: PMC6130883 DOI: 10.1371/journal.pone.0203707] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 08/24/2018] [Indexed: 12/30/2022] Open
Abstract
Hyperammonemia is the common biochemical hallmark of urea cycle disorders, activating neurotoxic pathways. If untreated, affected individuals have a high risk of irreversible brain damage and mortality. Here we show that acute hyperammonemia strongly enhances transamination-dependent formation of osmolytic glutamine and excitatory glutamate, thereby inducing neurotoxicity and death in ammoniotelic zebrafish larvae via synergistically acting overactivation of NMDA receptors and bioenergetic impairment induced by depletion of 2-oxoglutarate. Intriguingly, specific and irreversible inhibition of ornithine aminotransferase (OAT) by 5-fluoromethylornithine rescues zebrafish from lethal concentrations of ammonium acetate and corrects hyperammonemia-induced biochemical alterations. Thus, OAT inhibition is a promising and effective therapeutic approach for preventing neurotoxicity and mortality in acute hyperammonemia.
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Affiliation(s)
- Matthias Zielonka
- University Hospital Heidelberg, Center for Child and Adolescent Medicine, Division for Pediatric Neurology and Metabolic Medicine, Heidelberg, Germany
- Heidelberg Research Center for Molecular Medicine (HRCMM), Heidelberg, Germany
- * E-mail:
| | - Maximilian Breuer
- University Hospital Heidelberg, Center for Child and Adolescent Medicine, Division for Pediatric Neurology and Metabolic Medicine, Heidelberg, Germany
| | - Jürgen Günther Okun
- University Hospital Heidelberg, Center for Child and Adolescent Medicine, Division for Pediatric Neurology and Metabolic Medicine, Heidelberg, Germany
| | - Matthias Carl
- Heidelberg University, Medical Faculty Mannheim, Department of Cell and Molecular Biology, Mannheim, Germany
- University of Trento, Center for Integrative Biology (CIBIO), Laboratory of Translational Neurogenetics, Trento, Italy
| | - Georg Friedrich Hoffmann
- University Hospital Heidelberg, Center for Child and Adolescent Medicine, Division for Pediatric Neurology and Metabolic Medicine, Heidelberg, Germany
| | - Stefan Kölker
- University Hospital Heidelberg, Center for Child and Adolescent Medicine, Division for Pediatric Neurology and Metabolic Medicine, Heidelberg, Germany
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Khoja S, Nitzahn M, Hermann K, Truong B, Borzone R, Willis B, Rudd M, Palmer DJ, Ng P, Brunetti-Pierri N, Lipshutz GS. Conditional disruption of hepatic carbamoyl phosphate synthetase 1 in mice results in hyperammonemia without orotic aciduria and can be corrected by liver-directed gene therapy. Mol Genet Metab 2018; 124:243-253. [PMID: 29801986 PMCID: PMC6076338 DOI: 10.1016/j.ymgme.2018.04.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 04/02/2018] [Accepted: 04/02/2018] [Indexed: 02/06/2023]
Abstract
Carbamoyl phosphate synthetase 1 (CPS1) is a urea cycle enzyme that forms carbamoyl phosphate from bicarbonate, ammonia and ATP. Bi-allelic mutations of the CPS1 gene result in a urea cycle disorder presenting with hyperammonemia, often with reduced citrulline, and without orotic aciduria. CPS1 deficiency is particularly challenging to treat and lack of early recognition typically results in early neonatal death. Therapeutic interventions have limited efficacy and most patients develop long-term neurologic sequelae. Using transgenic techniques, we generated a conditional Cps1 knockout mouse. By loxP/Cre recombinase technology, deletion of the Cps1 locus was achieved in adult transgenic animals using a Cre recombinase-expressing adeno-associated viral vector. Within four weeks from vector injection, all animals developed hyperammonemia without orotic aciduria and died. Minimal CPS1 protein was detectable in livers. To investigate the efficacy of gene therapy for CPS deficiency following knock-down of hepatic endogenous CPS1 expression, we injected these mice with a helper-dependent adenoviral vector (HDAd) expressing the large murine CPS1 cDNA under control of the phosphoenolpyruvate carboxykinase promoter. Liver-directed HDAd-mediated gene therapy resulted in survival, normalization of plasma ammonia and glutamine, and 13% of normal Cps1 expression. A gender difference in survival suggests that female mice may require higher hepatic CPS1 expression. We conclude that this conditional murine model recapitulates the clinical and biochemical phenotype detected in human patients with CPS1 deficiency and will be useful to investigate ammonia-mediated neurotoxicity and for the development of cell- and gene-based therapeutic approaches.
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Affiliation(s)
- Suhail Khoja
- Departments of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States
| | - Matt Nitzahn
- Departments of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States; Molecular Biology Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States
| | - Kip Hermann
- Departments of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States; Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States
| | - Brian Truong
- Departments of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States; Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States
| | | | - Brandon Willis
- Mouse Biology Program (MBP), University of California, Davis, United States
| | - Mitchell Rudd
- Departments of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States
| | - Donna J Palmer
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, United States
| | - Philip Ng
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, United States
| | - Nicola Brunetti-Pierri
- Telethon Institute of Genetics and Medicine, Naples, Italy; Department of Translational Medicine, Federico II University of Naples, Naples, Italy
| | - Gerald S Lipshutz
- Departments of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States; Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States; Molecular Biology Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States; Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States; Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States; Psychiatry, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States; Intellectual and Developmental Disabilities Research Center at UCLA, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States; Semel Institute for Neuroscience, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States.
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Jang YJ, LaBella AL, Feeney TP, Braverman N, Tuchman M, Morizono H, Ah Mew N, Caldovic L. Disease-causing mutations in the promoter and enhancer of the ornithine transcarbamylase gene. Hum Mutat 2018; 39:527-536. [PMID: 29282796 DOI: 10.1002/humu.23394] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 12/19/2017] [Accepted: 12/21/2017] [Indexed: 12/17/2022]
Abstract
The ornithine transcarbamylase (OTC) gene is on the X chromosome and its product catalyzes the formation of citrulline from ornithine and carbamylphosphate in the urea cycle. About 10%-15% of patients, clinically diagnosed with OTC deficiency (OTCD), lack identifiable mutations in the coding region or splice junctions of the OTC gene on routine molecular testing. We collected DNA from such patients via retrospective review and by prospective enrollment. In nine of 38 subjects (24%), we identified a sequence variant in the OTC regulatory regions. Eight subjects had unique sequence variants in the OTC promoter and one subject had a novel sequence variant in the OTC enhancer. All sequence variants affect positions that are highly conserved in mammalian OTC genes. Functional studies revealed reduced reporter gene expression with all sequence variants. Two sequence variants caused decreased binding of the HNF4 transcription factor to its mutated binding site. Bioinformatic analyses combined with functional assays can be used to identify and authenticate pathogenic sequence variants in regulatory regions of the OTC gene, in other urea cycle disorders or other inborn errors of metabolism.
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Affiliation(s)
- Yoon J Jang
- Center for Genetic Medicine Research, Children's National Health System, Washington, District of Columbia
| | - Abigail L LaBella
- Department of Biological Sciences, Vanderbilt University, Nashville, Tennessee
| | - Timothy P Feeney
- Harvard T.H. Chan School of Public Health, Harvard University, Cambridge, Massachusetts
| | - Nancy Braverman
- McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Mendel Tuchman
- Center for Genetic Medicine Research, Children's National Health System, Washington, District of Columbia
| | - Hiroki Morizono
- Center for Genetic Medicine Research, Children's National Health System, Washington, District of Columbia
| | - Nicholas Ah Mew
- Center for Translational Sciences, Children's National Health System, Washington, District of Columbia
| | - Ljubica Caldovic
- Center for Genetic Medicine Research, Children's National Health System, Washington, District of Columbia
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Chen X, Yuan L, Sun M, Liu Q, Wu Y. Two novel CPS1 mutations in a case of carbamoyl phosphate synthetase 1 deficiency causing hyperammonemia and leukodystrophy. J Clin Lab Anal 2018; 32:e22375. [PMID: 29314318 DOI: 10.1002/jcla.22375] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 12/02/2017] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Carbamoyl phosphate synthetase 1 deficiency (CPS1D) is a rare autosomal recessive disorder of the urea cycle, mostly characterized by hyperammonemia and the concomitant leukodystrophy. The onset of CPS1D can be at any age, and the clinical manifestations are variable and atypical. Genetic tests are indispensable for accurate diagnosis of CPS1D on the basis of biochemical tests. METHODS Blood tandem mass spectrometric analysis and urea organic acidemia screening were performed on a Chinese neonatal patient with low activity, recurrent seizures, and hyperammonemia. Next-generation sequencing and Sanger sequencing were followed up for making a definite diagnosis. Bioinformatics tools were used for the conservation analysis and pathogenicity predictions of the identified mutations. RESULTS Increased lactate in urea and decreased citrulline in blood were detected in the patient. Two novel mutations (c.173G>T, p.G58V in exon 2 and c.796G>A, p.G266R in exon 8) in CPS1 identified in the neonatal patient were found through coseparation verification. Both of the two mutations were predicted to be deleterious, and the two relevant amino acids exerted highly evolutionarily conserved. The final diagnosis of the patient was compound heterozygous CPS1D. CONCLUSION This study described the specific clinical characteristics and the variations of physiological and biochemical indices in a Chinese neonatal patient with CPS1D, which facilitated the diagnosis and mechanism research of the disease. Two novel causative missense mutations were identified, which enriched the mutation spectrum of CPS1D in China and worldwide. Advice of prenatal diagnosis was given to the family for a new pregnancy.
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Affiliation(s)
- Xihui Chen
- Department of Biochemistry and Molecular Biology, Fourth Military Medical University, Xi'an, China.,Center for DNA Typing, Fourth Military Medical University, Xi'an, China
| | - Lijuan Yuan
- Department of Biochemistry and Molecular Biology, Fourth Military Medical University, Xi'an, China.,Center for DNA Typing, Fourth Military Medical University, Xi'an, China.,Department of General Surgery, Tangdu Hospital, Fourth Military Medical Universiy, Xi'an, China
| | - Mao Sun
- Department of Biochemistry and Molecular Biology, Fourth Military Medical University, Xi'an, China.,Center for DNA Typing, Fourth Military Medical University, Xi'an, China
| | - Qingbo Liu
- Department of Biochemistry and Molecular Biology, Fourth Military Medical University, Xi'an, China.,Center for DNA Typing, Fourth Military Medical University, Xi'an, China
| | - Yuanming Wu
- Department of Biochemistry and Molecular Biology, Fourth Military Medical University, Xi'an, China.,Center for DNA Typing, Fourth Military Medical University, Xi'an, China
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40
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Meyburg J, Opladen T, Spiekerkötter U, Schlune A, Schenk JP, Schmidt J, Weitz J, Okun J, Bürger F, Omran TB, Abdoh G, Al Rifai H, Monavari A, Konstantopoulou V, Kölker S, Yudkoff M, Hoffmann GF. Human heterologous liver cells transiently improve hyperammonemia and ureagenesis in individuals with severe urea cycle disorders. J Inherit Metab Dis 2018; 41:81-90. [PMID: 29027067 DOI: 10.1007/s10545-017-0097-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 09/19/2017] [Accepted: 09/22/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Urea cycle disorders (UCDs) still have a poor prognosis despite several therapeutic advancements. As liver transplantation can provide a cure, liver cell therapy (LCT) might be a new therapeutic option in these patients. METHODS Twelve patients with severe UCDs were included in this prospective clinical trial. Patients received up to six infusions of cryopreserved human heterologous liver cells via a surgically placed catheter in the portal vein. Portal vein pressure, portal vein flow, and vital signs were monitored continuously. Calcineurin inhibitors and steroids were used for immunosuppression. In four patients, ureagenesis was determined with stable isotopes. Number and severity of hyperammonemic events and side effects of immunosuppression were analyzed during an observation period of up to 2 years. RESULTS No study-related mortality was observed. The application catheter dislocated in two children. No significant side effects of catheter application or cell infusion were noted in the other ten patients. The overall incidence of infections did not differ significantly from a historical control group, and no specific side effects of immunosuppression were found. Seven patients were treated per protocol and could be analyzed for efficacy. Severe metabolic crises could be prevented in all of these patients, moderate crises in four of seven. Ureagenesis increased after cell infusion in all patients investigated. CONCLUSIONS We found a favorable safety profile with respect to catheter placement, intraportal liver cell infusion, and immunosuppression. More than half of the children treated per protocol experienced metabolic stabilization and could be safely bridged to liver transplantation.
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Affiliation(s)
- Jochen Meyburg
- Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany.
| | - Thomas Opladen
- Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany
| | - Ute Spiekerkötter
- Department of General Pediatrics, Neonatology and Paediatric Cardiology, Medical Faculty, Heinrich-Heine-University, Duesseldorf, Germany
- Division of General Pediatrics, University Children's Hospital, Freiburg, Germany
| | - Andrea Schlune
- Department of General Pediatrics, Neonatology and Paediatric Cardiology, Medical Faculty, Heinrich-Heine-University, Duesseldorf, Germany
| | - Jens-Peter Schenk
- Division of Pediatric Radiology, Department of Diagnostic and Interventional Radiology, University Hospital, Heidelberg, Germany
| | - Jan Schmidt
- Department of Visceral and Transplant Surgery, University Hospital, Heidelberg, Germany
| | - Jürgen Weitz
- Department of Visceral and Transplant Surgery, University Hospital, Heidelberg, Germany
| | - Jürgen Okun
- Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany
| | - Friederike Bürger
- Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany
| | - Tawfeg Ben Omran
- Department of Pediatrics, Hamad Medical Corporation, Doha, Qatar
| | - Ghassan Abdoh
- Department of Pediatrics, Hamad Medical Corporation, Doha, Qatar
| | - Hilal Al Rifai
- Department of Pediatrics, Hamad Medical Corporation, Doha, Qatar
| | - Ahmad Monavari
- National Centre of Inherited Metabolic Disorders, Dublin, Ireland
| | - Vassiliki Konstantopoulou
- Division of Pulmonology, Allergology, Endocrinology, and Metabolic Medicine, University Children's Hospital, Vienna, Austria
| | - Stefan Kölker
- Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany
| | - Marc Yudkoff
- Division of Metabolic Diseases, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Georg F Hoffmann
- Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany
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Maines E, Piccoli G, Pascarella A, Colucci F, Burlina AB. Inherited hyperammonemias: a Contemporary view on pathogenesis and diagnosis. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2018.1409108] [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: 10/18/2022]
Affiliation(s)
- Evelina Maines
- Pediatric Unit, Provincial Centre for Rare Diseases, Department of Women’s and Children’s Health, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
| | - Giovanni Piccoli
- CIBIO - Centre for integrative biology, Università degli Studi di Trento, Italy & Dulbecco Telethon Institute, Trento, Italy
| | - Antonia Pascarella
- Division of Inherited Metabolic Diseases, Reference Centre Expanded Newborn Screening, Department of Women’s and Children’s Health, University Hospital, Padova, Italy
| | - Francesca Colucci
- Division of Inherited Metabolic Diseases, Reference Centre Expanded Newborn Screening, Department of Women’s and Children’s Health, University Hospital, Padova, Italy
| | - Alberto B. Burlina
- Division of Inherited Metabolic Diseases, Reference Centre Expanded Newborn Screening, Department of Women’s and Children’s Health, University Hospital, Padova, Italy
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Bigot A, Tchan MC, Thoreau B, Blasco H, Maillot F. Liver involvement in urea cycle disorders: a review of the literature. J Inherit Metab Dis 2017; 40:757-769. [PMID: 28900784 DOI: 10.1007/s10545-017-0088-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 08/13/2017] [Accepted: 08/29/2017] [Indexed: 12/20/2022]
Abstract
Urea cycle disorders (UCDs) are inborn errors of metabolism of the nitrogen detoxification pathway and encompass six principal enzymatic deficiencies. The aging of UCD patients leads to a better knowledge of the long-term natural history of the condition and to the reporting of previously unnoticed manifestations. Despite historical evidence of liver involvement in UCDs, little attention has been paid to this organ until recently. Hence, we reviewed the available scientific evidence on acute and chronic liver dysfunction and liver carcinogenesis in UCDs and discuss their pathophysiology. Overall, liver involvement, such as acute liver failure or steatotic-like disease, which may evolve toward cirrhosis, has been reported in all six main UCDs. Excessive glycogen storage is also a prominent histologic feature, and hypoglycemia has been reported in citrin deficiency. Hepatocarcinomas seem frequent in some UCDs, such as in citrin deficiency, and can sometimes occur in non-cirrhotic patients. UCDs may differ in liver involvement according to the enzymatic deficiency. Ornithine transcarbamylase deficiency may be associated more with acute liver failure and argininosuccinic aciduria with chronic liver failure and cirrhosis. Direct toxicity of metabolites, downstream metabolic deficiencies, impaired tricarboxylic acid cycle, oxidative stress, mitochondrial dysfunction, energy deficit, and putative toxicity of therapies combine in various ways to cause the different liver diseases reported.
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Affiliation(s)
- Adrien Bigot
- CHRU de Tours, service médecine interne, Tours, France.
- CHRU de Tours, centre de référence des maladies héréditaires du métabolisme, Tours, France.
- Department of Genetic Medicine, Westmead Hospital, Sydney, Australia.
- Service de Médecine Interne, Hôpital Bretonneau, 2, boulevard Tonnelle, 37044, Tours, France.
| | - Michel C Tchan
- Department of Genetic Medicine, Westmead Hospital, Sydney, Australia
| | - Benjamin Thoreau
- CHRU de Tours, service médecine interne, Tours, France
- CHRU de Tours, centre de référence des maladies héréditaires du métabolisme, Tours, France
- Université François Rabelais, Tours, France
- UMR INSERM U 1069, Tours, France
| | - Hélène Blasco
- CHRU de Tours, centre de référence des maladies héréditaires du métabolisme, Tours, France
- Université François Rabelais, Tours, France
- CHRU de Tours, service de biochimie-biologie moléculaire, Tours, France
- UMR INSERM U930, 37000, Tours, France
| | - François Maillot
- CHRU de Tours, service médecine interne, Tours, France
- CHRU de Tours, centre de référence des maladies héréditaires du métabolisme, Tours, France
- Université François Rabelais, Tours, France
- UMR INSERM U 1069, Tours, France
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