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Hegarty R, Thompson RJ. Genetic aetiologies of acute liver failure. J Inherit Metab Dis 2024; 47:582-597. [PMID: 38499319 DOI: 10.1002/jimd.12733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 03/11/2024] [Accepted: 03/12/2024] [Indexed: 03/20/2024]
Abstract
Acute liver failure (ALF) is a rare, rapidly evolving, clinical syndrome with devastating consequences where definitive treatment is by emergency liver transplantation. Establishing a diagnosis can be challenging and, historically, the cause of ALF was unidentified in up to half of children. However, recent technological and clinical advances in genomic medicine have led to an increasing proportion being diagnosed with monogenic aetiologies of ALF. The conditions encountered include a diverse group of inherited metabolic disorders each with prognostic and treatment implications. Often these disorders are clinically indistinguishable and may even mimic disorders of immune regulation or red cell disorders. Rapid genomic sequencing for children with ALF is, therefore, a key component in the diagnostic work up today. This review focuses on the monogenic aetiologies of ALF.
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Affiliation(s)
- Robert Hegarty
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital, London, UK
- Institute of Liver Studies, King's College London, London, UK
| | - Richard J Thompson
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital, London, UK
- Institute of Liver Studies, King's College London, London, UK
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2
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Tsykunova G, Kristensen E, Stray-Pedersen A, Bruserud Ø, Sørensen IW, Bruserud Ø, Tvedt THA. Adult presentation of ornithine transcarbamylase deficiency: a possible cause of hyperammonemia after high-dose chemotherapy and stem cell transplantation. Hematology 2023; 28:2265187. [PMID: 38078487 DOI: 10.1080/16078454.2023.2265187] [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: 06/03/2023] [Accepted: 09/26/2023] [Indexed: 12/18/2023] Open
Abstract
Hyperammonemia is a rare and often fatal complication following the conditioning therapy in autologous and allogeneic stem cell transplant recipients. It is characterized by anorexia, vomiting, lethargy and coma without any other apparent cause. The diagnosis is often delayed because symptoms can be subtle and ammonia is usually not included among the routine analyzes. Previous reports have not identified the molecular mechanisms behind hyperammonemia in stem cell transplant recipients. Urea cycle disorders (UCDs) are inborn errors of metabolism leading to hyperammonemia that usually presents in early childhood, whereas first presentation in adults is less common. Here we describe an adult woman with hyperammonemia following autologous stem cell transplantation for multiple myeloma. No apparent cause of hyperammonemia was identified, including portosystemic shunting, liver dysfunction or recent hyperammonemia-inducing chemotherapy. Hyperammonemia, normal blood glucose as well as anion gap and a previous history of two male newborns that died early after birth, prompted biochemical and genetic investigations for a UCD. A heterozygous variant in the X-linked gene encoding ornithine transcarbamylase (OTC) was identified and was regarded as a cause of UCD. The patient improved after treatment with nitrogen scavengers and high caloric intake according to a UCD protocol. This case report suggests that UCD should be considered as a possible cause of hyperammonemia following stem cell transplantation.
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Affiliation(s)
- Galina Tsykunova
- Department of Medicine Haukeland University Hospital, Bergen, Norway
| | - Erle Kristensen
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Asbjørg Stray-Pedersen
- The National Unit for Newborn Screening, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Øyvind Bruserud
- Department of Anesthesiology and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Ida Wiig Sørensen
- Department of Medical Genetics, Haukeland University Hospital, Bergen, Norway
| | - Øystein Bruserud
- Department of Medicine Haukeland University Hospital, Bergen, Norway
- Section for Hematology, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Tor Henrik Anderson Tvedt
- Department of Medicine Haukeland University Hospital, Bergen, Norway
- Department of Haematology, Oslo University Hospital, Oslo, Norway
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3
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Murali CN, Barber JR, McCarter R, Zhang A, Gallant N, Simpson K, Dorrani N, Wilkening GN, Hays RD, Lichter-Konecki U, Burrage LC, Nagamani SCS. Health-related quality of life in a systematically assessed cohort of children and adults with urea cycle disorders. Mol Genet Metab 2023; 140:107696. [PMID: 37690181 PMCID: PMC10866211 DOI: 10.1016/j.ymgme.2023.107696] [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: 06/21/2023] [Revised: 09/01/2023] [Accepted: 09/02/2023] [Indexed: 09/12/2023]
Abstract
PURPOSE Individuals with urea cycle disorders (UCDs) may develop recurrent hyperammonemia, episodic encephalopathy, and neurological sequelae which can impact Health-related Quality of Life (HRQoL). To date, there have been no systematic studies of HRQoL in people with UCDs. METHODS We reviewed HRQoL and clinical data for 190 children and 203 adults enrolled in a multicenter UCD natural history study. Physical and psychosocial HRQoL in people with UCDs were compared to HRQoL in healthy people and people with phenylketonuria (PKU) and diabetes mellitus. We assessed relationships between HRQoL, UCD diagnosis, and disease severity. Finally, we calculated sample sizes required to detect changes in these HRQoL measures. RESULTS Individuals with UCDs demonstrated worse physical and psychosocial HRQoL than their healthy peers and peers with PKU and diabetes. In children, HRQoL scores did not differ by diagnosis or severity. In adults, individuals with decreased severity had worse psychosocial HRQoL. Finally, we show that a large number of individuals would be required in clinical trials to detect differences in HRQoL in UCDs. CONCLUSION Individuals with UCDs have worse HRQoL compared to healthy individuals and those with PKU and diabetes. Future work should focus on the impact of liver transplantation and other clinical variables on HRQoL in UCDs.
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Affiliation(s)
- Chaya N Murali
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Texas Children's Hospital, Houston, TX, USA
| | - John R Barber
- Children's National Health System, Washington, DC, USA
| | | | - Anqing Zhang
- Children's National Health System, Washington, DC, USA
| | - Natalie Gallant
- Department of Pediatrics, University of California Irvine, Irvine, CA, USA
| | - Kara Simpson
- Children's National Health System, Washington, DC, USA
| | - Naghmeh Dorrani
- Department of Human Genetics, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Ron D Hays
- Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Uta Lichter-Konecki
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Lindsay C Burrage
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Texas Children's Hospital, Houston, TX, USA
| | - Sandesh C S Nagamani
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Texas Children's Hospital, Houston, TX, USA.
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4
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Hadj TB, Te VLT, Le Guyader M, Voyer A, Durand-Maugard C, Galmiche A, Garçon L, Demagny J. Argininemia and vitamin K-dependent coagulation factors deficiency: A case report and a brief review of the literature. Thromb Res 2023; 229:42-45. [PMID: 37393626 DOI: 10.1016/j.thromres.2023.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 06/21/2023] [Accepted: 06/29/2023] [Indexed: 07/04/2023]
Affiliation(s)
- Tasnim Bel Hadj
- Service d'Hématologie Biologique, CHU Amiens-Picardie, Amiens, France
| | - Valérie Li Thiao Te
- Service d'Oncologie-Hématologie Pédiatrique, CHU Amiens-Picardie, Amiens, France
| | - Maïlys Le Guyader
- Service d'Hématologie Biologique, CHU Amiens-Picardie, Amiens, France
| | - Annelise Voyer
- Service d'Hématologie Biologique, CHU Amiens-Picardie, Amiens, France
| | | | | | - Loïc Garçon
- Service d'Hématologie Biologique, CHU Amiens-Picardie, Amiens, France; HEMATIM UR4666, Univ. Picardie Jules Verne, Amiens, France
| | - Julien Demagny
- Service d'Hématologie Biologique, CHU Amiens-Picardie, Amiens, France; HEMATIM UR4666, Univ. Picardie Jules Verne, Amiens, France.
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Seker Yilmaz B, Baruteau J, Arslan N, Aydin HI, Barth M, Bozaci AE, Brassier A, Canda E, Cano A, Chronopoulou E, Connolly GM, Damaj L, Dawson C, Dobbelaere D, Douillard C, Eminoglu FT, Erdol S, Ersoy M, Fang S, Feillet F, Gokcay G, Goksoy E, Gorce M, Inci A, Kadioglu B, Kardas F, Kasapkara CS, Kilic Yildirim G, Kor D, Kose M, Marelli C, Mundy H, O’Sullivan S, Ozturk Hismi B, Ramachandran R, Roubertie A, Sanlilar M, Schiff M, Sreekantam S, Stepien KM, Uzun Unal O, Yildiz Y, Zubarioglu T, Gissen P. Three-Country Snapshot of Ornithine Transcarbamylase Deficiency. Life (Basel) 2022; 12:1721. [PMID: 36362876 PMCID: PMC9695856 DOI: 10.3390/life12111721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 11/16/2022] Open
Abstract
X-linked ornithine transcarbamylase deficiency (OTCD) is the most common urea cycle defect. The disease severity ranges from asymptomatic carrier state to severe neonatal presentation with hyperammonaemic encephalopathy. We audited the diagnosis and management of OTCD, using an online 12-question-survey that was sent to 75 metabolic centres in Turkey, France and the UK. Thirty-nine centres responded and 495 patients were reported in total. A total of 208 French patients were reported, including 71 (34%) males, 86 (41%) symptomatic and 51 (25%) asymptomatic females. Eighty-five Turkish patients included 32 (38%) males, 39 (46%) symptomatic and 14 (16%) asymptomatic females. Out of the 202 UK patients, 66 (33%) were male, 83 (41%) asymptomatic and 53 (26%) symptomatic females. A total of 19%, 12% and 7% of the patients presented with a neonatal-onset phenotype in France, Turkey and the UK, respectively. Vomiting, altered mental status and encephalopathy were the most common initial symptoms in all three countries. While 69% in France and 79% in Turkey were receiving protein restriction, 42% were on a protein-restricted diet in the UK. A total of 76%, 47% and 33% of patients were treated with ammonia scavengers in Turkey, France and the UK, respectively. The findings of our audit emphasize the differences and similarities in manifestations and management practices in three countries.
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Affiliation(s)
- Berna Seker Yilmaz
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK
| | - Julien Baruteau
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK
- National Institute of Health Research Great Ormond Street Biomedical Research Centre, London WC1N 1EH, UK
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - Nur Arslan
- Paediatric Metabolic Medicine Department, Dokuz Eylul University Faculty of Medicine, Izmir 35340, Turkey
| | - Halil Ibrahim Aydin
- Paediatric Metabolic Medicine Department, Baskent University Faculty of Medicine, Ankara 06490, Turkey
| | - Magalie Barth
- Centre de Référence des Maladies Héréditaires du Métabolisme, CHU Angers, 4 rue Larrey, CEDEX 9, 49933 Angers, France
| | - Ayse Ergul Bozaci
- Paediatric Metabolic Medicine Department, Diyarbakir Children’s Hospital, Diyarbakir 21100, Turkey
| | - Anais Brassier
- Reference Center for Inborn Errors of Metabolism, Necker University Hospital, APHP and University of Paris Cité, 75015 Paris, France
| | - Ebru Canda
- Paediatric Metabolic Medicine Department, Ege University Faculty of Medicine, Izmir 35100, Turkey
| | - Aline Cano
- Reference Center of Inherited Metabolic Disorders, Timone Enfants Hospital, 264 rue Saint-Pierre, 13005 Marseille, France
| | - Efstathia Chronopoulou
- Department of Inherited Metabolic Disease, Division of Women’s and Children’s Services, University Hospitals Bristol NHS Foundation Trust, Bristol BS1 3NU, UK
| | | | - Lena Damaj
- Centre de Compétence Maladies Héréditaires du Métabolisme, CHU Hôpital Sud, CEDEX 2, 35203 Rennes, France
| | - Charlotte Dawson
- Metabolic Medicine Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK
| | - Dries Dobbelaere
- Medical Reference Center for Inherited Metabolic Diseases, Jeanne de Flandre University Hospital and RADEME Research Team for Rare Metabolic and Developmental Diseases, EA 7364 CHRU Lille, 59000 Lille, France
| | - Claire Douillard
- Medical Reference Center for Inherited Metabolic Diseases, Jeanne de Flandre University Hospital and RADEME Research Team for Rare Metabolic and Developmental Diseases, EA 7364 CHRU Lille, 59000 Lille, France
| | - Fatma Tuba Eminoglu
- Paediatric Metabolic Medicine Department, Ankara University Faculty of Medicine, Ankara 06080, Turkey
| | - Sahin Erdol
- Paediatric Metabolic Medicine Department, Uludag University Faculty of Medicine, Bursa 16059, Turkey
| | - Melike Ersoy
- Paediatric Metabolic Medicine Department, Dr Sadi Konuk Reseach & Training Hospital, Istanbul 34450, Turkey
| | - Sherry Fang
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - François Feillet
- Centre de Référence des Maladies Métaboliques de Nancy, CHU Brabois Enfants, 5 Rue du Morvan, 54500 Vandœuvre-lès-Nancy, France
| | - Gulden Gokcay
- Paediatric Metabolic Medicine Department, Istanbul University Istanbul Faculty of Medicine, Istanbul 34093, Turkey
| | - Emine Goksoy
- Paediatric Metabolic Medicine Department, Cengiz Gokcek Children’s Hospital, Gaziantep 27010, Turkey
| | - Magali Gorce
- Centre de Référence des Maladies Rares du Métabolisme, Hôpital des Enfants—CHU Toulouse, 330 Avenue de Grande-Bretagne, CEDEX 9, 31059 Toulouse, France
| | - Asli Inci
- Paediatric Metabolic Medicine Department, Gazi University Faculty of Medicine, Ankara 06500, Turkey
| | - Banu Kadioglu
- Paediatric Metabolic Medicine Department, Konya City Hospital, Konya 42020, Turkey
| | - Fatih Kardas
- Paediatric Metabolic Medicine Department, Erciyes University Faculty of Medicine, Kayseri 38030, Turkey
| | - Cigdem Seher Kasapkara
- Paediatric Metabolic Medicine Department, Ankara Yildirim Beyazit University Faculty of Medicine, Ankara 06800, Turkey
| | - Gonca Kilic Yildirim
- Paediatric Metabolic Medicine Department, Osmangazi University Faculty of Medicine, Eskisehir 26480, Turkey
| | - Deniz Kor
- Paediatric Metabolic Medicine Department, Cukurova University Faculty of Medicine, Adana 01250, Turkey
| | - Melis Kose
- Paediatric Metabolic Medicine Department, Faculty of Medicine, Izmir Katip Celebi University, Izmir 35620, Turkey
| | - Cecilia Marelli
- MMDN, University Montpellier, EPHE, INSERM, 34090 Montpellier, France
- Expert Center for Metabolic and Neurogenetic Diseases, Centre Hospitalier Universitaire (CHU), 34090 Montpellier, France
| | - Helen Mundy
- Evelina Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
| | | | - Burcu Ozturk Hismi
- Paediatric Metabolic Medicine Department, Marmara University Faculty of Medicine, Istanbul 34854, Turkey
| | | | - Agathe Roubertie
- MMDN, University Montpellier, EPHE, INSERM, 34090 Montpellier, France
- Expert Center for Metabolic and Neurogenetic Diseases, Centre Hospitalier Universitaire (CHU), 34090 Montpellier, France
| | - Mehtap Sanlilar
- Paediatric Metabolic Medicine Department, Antalya Training and Research Hospital, Antalya 07100, Turkey
| | - Manuel Schiff
- Reference Center for Inborn Errors of Metabolism, Necker University Hospital, APHP and University of Paris Cité, 75015 Paris, France
| | - Srividya Sreekantam
- Birmingham Women’s and Children’s Hospital NHS Foundation Trust, Birmingham B4 6NH, UK
| | - Karolina M. Stepien
- Adult Inherited Metabolic Diseases, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK
| | - Ozlem Uzun Unal
- Paediatric Metabolic Medicine Department, Kocaeli University Faculty of Medicine, Kocaeli 41380, Turkey
| | - Yilmaz Yildiz
- Paediatric Metabolic Medicine Department, Hacettepe University Faculty of Medicine, Ankara 06230, Turkey
| | - Tanyel Zubarioglu
- Paediatric Metabolic Medicine Department, Istanbul University-Cerrahpasa Faculty of Medicine, Istanbul 34096, Turkey
| | - Paul Gissen
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK
- National Institute of Health Research Great Ormond Street Biomedical Research Centre, London WC1N 1EH, UK
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
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Laemmle A, Poms M, Hsu B, Borsuk M, Rüfenacht V, Robinson J, Sadowski MC, Nuoffer J, Häberle J, Willenbring H. Aquaporin 9 induction in human iPSC-derived hepatocytes facilitates modeling of ornithine transcarbamylase deficiency. Hepatology 2022; 76:646-659. [PMID: 34786702 PMCID: PMC9295321 DOI: 10.1002/hep.32247] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 10/30/2021] [Accepted: 11/14/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS Patient-derived human-induced pluripotent stem cells (hiPSCs) differentiated into hepatocytes (hiPSC-Heps) have facilitated the study of rare genetic liver diseases. Here, we aimed to establish an in vitro liver disease model of the urea cycle disorder ornithine transcarbamylase deficiency (OTCD) using patient-derived hiPSC-Heps. APPROACH AND RESULTS Before modeling OTCD, we addressed the question of why hiPSC-Heps generally secrete less urea than adult primary human hepatocytes (PHHs). Because hiPSC-Heps are not completely differentiated and maintain some characteristics of fetal PHHs, we compared gene-expression levels in human fetal and adult liver tissue to identify genes responsible for reduced urea secretion in hiPSC-Heps. We found lack of aquaporin 9 (AQP9) expression in fetal liver tissue as well as in hiPSC-Heps, and showed that forced expression of AQP9 in hiPSC-Heps restores urea secretion and normalizes the response to ammonia challenge by increasing ureagenesis. Furthermore, we proved functional ureagenesis by challenging AQP9-expressing hiPSC-Heps with ammonium chloride labeled with the stable isotope [15 N] (15 NH4 Cl) and by assessing enrichment of [15 N]-labeled urea. Finally, using hiPSC-Heps derived from patients with OTCD, we generated a liver disease model that recapitulates the hepatic manifestation of the human disease. Restoring OTC expression-together with AQP9-was effective in fully correcting OTC activity and normalizing ureagenesis as assessed by 15 NH4 Cl stable-isotope challenge. CONCLUSION Our results identify a critical role for AQP9 in functional urea metabolism and establish the feasibility of in vitro modeling of OTCD with hiPSC-Heps. By facilitating studies of OTCD genotype/phenotype correlation and drug screens, our model has potential for improving the therapy of OTCD.
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Affiliation(s)
- Alexander Laemmle
- Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell ResearchUniversity of California San FranciscoSan FranciscoCaliforniaUSA,Department of PediatricsUniversity Children's HospitalBernSwitzerland,University Institute of Clinical ChemistryUniversity of BernBernSwitzerland
| | - Martin Poms
- Division of Clinical Chemistry and BiochemistryUniversity Children’s Hospital ZurichZurichSwitzerland
| | - Bernadette Hsu
- Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell ResearchUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Mariia Borsuk
- University Institute of Clinical ChemistryUniversity of BernBernSwitzerland
| | - Véronique Rüfenacht
- Division of Metabolism and Children`s Research CenterUniversity Children’s HospitalZurichSwitzerland
| | - Joshua Robinson
- Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell ResearchUniversity of California San FranciscoSan FranciscoCaliforniaUSA,Center for Reproductive SciencesUniversity of California San FranciscoSan FranciscoCaliforniaUSA,Department of Obstetrics, Gynecology, and Reproductive SciencesUniversity of California San FranciscoSan FranciscoCaliforniaUSA,Department of PediatricsMedical GeneticsUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | | | - Jean‐Marc Nuoffer
- Department of PediatricsUniversity Children's HospitalBernSwitzerland,University Institute of Clinical ChemistryUniversity of BernBernSwitzerland
| | - Johannes Häberle
- Division of Metabolism and Children`s Research CenterUniversity Children’s HospitalZurichSwitzerland,Zurich Center for Integrative Human PhysiologyUniversity of ZurichZurichSwitzerland
| | - Holger Willenbring
- Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell ResearchUniversity of California San FranciscoSan FranciscoCaliforniaUSA,Department of SurgeryDivision of Transplant SurgeryUniversity of California San FranciscoSan FranciscoCaliforniaUSA,Liver CenterUniversity of California San FranciscoSan FranciscoCaliforniaUSA
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Benefits of tailored disease management in improving tremor, white matter hyperintensities, and liver enzymes in a child with heterozygous X-linked ornithine transcarbamylase deficiency. Mol Genet Metab Rep 2022; 33:100891. [PMID: 36620387 PMCID: PMC9817482 DOI: 10.1016/j.ymgmr.2022.100891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/23/2022] [Accepted: 06/24/2022] [Indexed: 01/11/2023] Open
Abstract
We report the case of a 19-month-old girl with late-onset ornithine transcarbamylase (OTC) deficiency initially referred to gastroenterology for intermittent vomiting lasting a year and abnormal liver enzymes (AST 730 U/L [reference range 26-55 U/L]; ALT 1213 U/L [reference range 11-30 U/L]) without hepatomegaly. While the patient was hospitalized for liver biopsy, intermittent tremors of the upper extremities with varying severity were noted. The patient was presumed to have hyperammonemia secondary to acute liver failure and was discharged after 5 days; follow-up monitoring led to readmission 7 days later. A brain MRI showed nonspecific bilateral pericallosal and bifrontal white matter FLAIR hyperintensities. These findings raised suspicion for a metabolic disease and prompted a genetics consultation. After inconclusive biochemical testing and worsening clinical status, rapid whole genome sequencing results were obtained identifying a novel, de novo, likely pathogenic, variant c.608C > T (p.Ser203Phe) in the OTC gene. The patient was promptly started on an oral nitrogen scavenger, citrulline supplementation, and protein restriction. Ammonia and glutamine levels normalized within 1 month of treatment and have stayed within the goal ranges with continued tailoring of treatment. Her parents noted resolution of vomiting and improved mood stability. Liver enzymes normalized after 2 months of treatment. The tremor, identified as asterixis, improved and a repeat brain MRI 3 months after the initial imaging showed near-complete resolution of previous white matter hyperintensities.
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Key Words
- ALT, alanine transaminase
- AST, aspartate aminotransferase
- Asterixis
- BASC-3, Behavior Assessment System for Children
- BCAA, branched-chain amino acid
- FLAIR, fluid-attenuated inversion recovery
- GGT, gamma-glutamyl transferase
- Late onset
- MRI, magnetic resonance imaging
- MRS, magnetic resonance spectroscopy
- Manifesting heterozygote
- OTC, ornithine transcarbamylase
- Ornithine transcarbamylase deficiency
- PT, prothrombin time
- Partial onset
- TID, 3 times a day
- UCD, urea cycle disorder
- Urea cycle disorder
- WPPSI-IV, Wechsler Preschool and Primary Scale of Intelligence
- X linked
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9
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Cui B, Wei L, Sun LY, Qu W, Zeng ZG, Liu Y, Zhu ZJ. The effect of liver transplantation for argininemia-the largest experiences in a single center. Transl Pediatr 2022; 11:495-504. [PMID: 35558983 PMCID: PMC9085954 DOI: 10.21037/tp-21-576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 01/27/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Argininemia, a rare urea cycle disorder resulting from an arginase-1 deficiency, is characterized by a progressive spastic paraplegia. While advances in diagnosis and treatment have increased the management of this condition, not all symptoms are resolved in response to traditional therapies. Interestingly, there exist some rare reports on the use of liver transplantation (LT) for the treatment of argininemia. METHODS We conducted a retrospective study of eleven patients with argininemia receiving a LT as performed at our center over the period from January 2015 to November 2019. These patients were included due to their poor responses to protein restriction diets and alternative therapies of nitrogen scavengers. Detailed information on coagulation, liver function, histopathological and morphological examination of liver samples, and other clinical presentations were extracted from these patients. A grading scale was used for evaluating the neurological status, classification of physical growth and quality of life of these patients in response to the LT. RESULTS Prior to LT, high levels of arginine were detected in all of argininemia patients and liver enzymes were elevated in nine of those patients. Nine patients presented with coagulation dysfunction without bleeding symptoms. Spastic paraplegia, irritability, intellectual developmental disability, and growth deficits were hallmarks of these nine patients, while four patients showed repeated, generalized tonic-clonic seizures before the operation. Seven novel mutations were found in these patients. The indication for LT in this series of patients was a presentation of progressive neurological impairments. After LT, the coagulation index and plasma arginine levels returned to normal and episodes of seizure were controlled in four patients. To date, all patients have survived and their LT has resulted a restoration of arginine metabolism and liver function, along with preventing further neurological deterioration, all of which provided an opportunity for future recuperation. Overall, the neurological status, growth deficits and quality of life were all significantly improved after LT with no evidence of severe complications. CONCLUSIONS LT can serve as an effective treatment for argininemia in patients who respond poorly to traditional therapy. An early intervention of LT should be conducted in these patients to prevent neurological damage and improve their quality of life.
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Affiliation(s)
- Bin Cui
- Liver Transplantation Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China.,National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Lin Wei
- Liver Transplantation Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China.,National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Li-Ying Sun
- Liver Transplantation Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China.,National Clinical Research Center for Digestive Diseases, Beijing, China.,Department of Critical Liver Diseases, Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Wei Qu
- Liver Transplantation Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China.,National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Zhi-Gui Zeng
- Liver Transplantation Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China.,National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Ying Liu
- Liver Transplantation Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China.,National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Zhi-Jun Zhu
- Liver Transplantation Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China.,National Clinical Research Center for Digestive Diseases, Beijing, China
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10
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Sysák R, Brennerová K, Krlín R, Štencl P, Rusňák I, Vargová M. Effect of Ornithine Transcarbamylase (OTC) Deficiency on Pregnancy and Puerperium. Diagnostics (Basel) 2022; 12:diagnostics12020415. [PMID: 35204506 PMCID: PMC8871159 DOI: 10.3390/diagnostics12020415] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 01/23/2022] [Accepted: 02/01/2022] [Indexed: 12/30/2022] Open
Abstract
Ornithine transcarbamylase (OTC) deficiency is the most common inherited metabolic disorder in urea cycles with an incidence of 1:14,000 live births. Pregnancy, childbirth and the postpartum period are considered challenging for women with this hereditary metabolic disorder, with a risk of hyperammonemia, especially in the first week after delivery. In our article, we discuss severe hepatic failure, a pregnancy complication in an OTC deficient patient that has not previously been published. Firstly, our aim is to highlight the need for a strict adherence to the recommendation of the gradual increase of protein intake during pregnancy and the importance of multidisciplinary monitoring of pregnant patients with OTC deficiency. Secondly, we refer to critical postpartum hyperammonemia in patients with this hereditary metabolic disorder.
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Affiliation(s)
- Rastislav Sysák
- 1st Department of Gynaecology and Obstetrics, Faculty of Medicine, Comenius University in Bratislava, 851 07 Bratislava, Slovakia; (P.Š.); (M.V.)
- Correspondence:
| | - Katarína Brennerová
- Department of Pediatrics, National Institute of Children’s Diseases, 831 01 Bratislava, Slovakia;
| | - Romana Krlín
- 2nd Department of Gynaecology and Obstetrics, Faculty of Medicine, Comenius University in Bratislava, 821 01 Bratislava, Slovakia;
| | - Peter Štencl
- 1st Department of Gynaecology and Obstetrics, Faculty of Medicine, Comenius University in Bratislava, 851 07 Bratislava, Slovakia; (P.Š.); (M.V.)
| | - Igor Rusňák
- 1st Department of Gynaecology and Obstetrics, Faculty of Medicine, Slovak Medical University, 831 01 Bratislava, Slovakia;
| | - Mária Vargová
- 1st Department of Gynaecology and Obstetrics, Faculty of Medicine, Comenius University in Bratislava, 851 07 Bratislava, Slovakia; (P.Š.); (M.V.)
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11
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Squires JE, Alonso EM, Ibrahim SH, Kasper V, Kehar M, Martinez M, Squires RH. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper on the Diagnosis and Management of Pediatric Acute Liver Failure. J Pediatr Gastroenterol Nutr 2022; 74:138-158. [PMID: 34347674 DOI: 10.1097/mpg.0000000000003268] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
ABSTRACT Pediatric acute liver failure (PALF) is a rare, rapidly progressive clinical syndrome with significant morbidity and mortality. The phenotype of PALF manifests as abrupt onset liver dysfunction, which can be brought via disparate etiology. Management is reliant upon intensive clinical care and support, often provided by the collaborative efforts of hepatologists, critical care specialists, and liver transplant surgeons. The construction of an age-based diagnostic approach, the identification of a potential underlying cause, and the prompt implementation of appropriate therapy can be lifesaving; however, the dynamic and rapidly progressive nature of PALF also demands that diagnostic inquiries be paired with monitoring strategies for the recognition and treatment of common complications of PALF. Although liver transplantation can provide a potential life-saving therapeutic option, the ability to confidently determine the certainness that liver transplant is needed for an individual child has been hampered by a lack of adequately tested clinical decision support tools and accurate predictive models. Given the accelerated progress in understanding PALF, we will provide clinical guidance to pediatric gastroenterologists and other pediatric providers caring for children with PALF by presenting the most recent advances in diagnosis, management, pathophysiology, and associated outcomes.
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Affiliation(s)
- James E Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Estella M Alonso
- Department Pediatric Hepatology, Ann and Robert H Lurie Children's Hospital, Chicago, Illinois, USA
| | - Samar H Ibrahim
- Department of Pediatrics, Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Vania Kasper
- Division of Pediatric Gastroenterology, Nutrition and Liver Diseases, Hasbro Children's Hospital, Providence, RI
| | - Mohit Kehar
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Mercedes Martinez
- Department of Pediatrics, Vagelos College of Physician and Surgeons, Columbia University, New York, NY
| | - Robert H Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
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12
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Mulroy E, Baschieri F, Magrinelli F, Latorre A, Cortelli P, Bhatia KP. Movement Disorders and Liver Disease. Mov Disord Clin Pract 2021; 8:828-842. [PMID: 34401403 PMCID: PMC8354085 DOI: 10.1002/mdc3.13238] [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: 11/17/2020] [Revised: 04/24/2021] [Accepted: 04/27/2021] [Indexed: 12/15/2022] Open
Abstract
The association of movement disorders with structural or functional hepatic disease occurs in three principal scenarios: (1) combined involvement of both organ systems from a single disease entity, (2) nervous system dysfunction resulting from exposure to toxic compounds in the setting of defective hepatic clearance, or (3) hepatic and/or neurological injury secondary to exposure to exogenous drugs or toxins. An important early step in the workup of any patient with combined movement disorders and liver disease is the exclusion of Wilson's disease. Diagnostic delay remains common for this treatable disorder, and this has major implications for patient outcomes. Thereafter, a structured approach integrating variables such as age of onset, tempo of progression, nature and severity of liver involvement, movement disorder phenomenology, exposure to drugs/toxins and laboratory/neuroimaging findings is key to ensuring timely diagnosis and disease‐specific therapy. Herein, we provide an overview of disorders which may manifest with a combination of movement disorders and liver disease, structured under the three headings as detailed above. In each section, the most common disorders are discussed, along with important clinical pearls, suggested diagnostic workup, differential diagnoses and where appropriate, treatment considerations.
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Affiliation(s)
- Eoin Mulroy
- Department of Clinical and Movement Neurosciences UCL Queen Square Institute of Neurology London United Kingdom
| | - Francesca Baschieri
- IRCCS Istituto delle Scienze Neurologiche di Bologna Bologna Italy.,Dipartimento di Scienze Biomediche e Neuromotorie Università di Bologna Bologna Italy
| | - Francesca Magrinelli
- Department of Clinical and Movement Neurosciences UCL Queen Square Institute of Neurology London United Kingdom.,Department of Neurosciences Biomedicine and Movement Sciences, University of Verona Verona Italy
| | - Anna Latorre
- Department of Clinical and Movement Neurosciences UCL Queen Square Institute of Neurology London United Kingdom
| | - Pietro Cortelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna Bologna Italy.,Dipartimento di Scienze Biomediche e Neuromotorie Università di Bologna Bologna Italy
| | - Kailash P Bhatia
- Department of Clinical and Movement Neurosciences UCL Queen Square Institute of Neurology London United Kingdom
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13
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Nagamani SCS, Ali S, Izem R, Schady D, Masand P, Shneider BL, Leung DH, Burrage LC. Biomarkers for liver disease in urea cycle disorders. Mol Genet Metab 2021; 133:148-156. [PMID: 33846069 PMCID: PMC8195846 DOI: 10.1016/j.ymgme.2021.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/03/2021] [Accepted: 04/04/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Urea cycle disorders (UCDs) are among the most common inborn errors of liver metabolism. As therapies for hyperammonemia associated with urea cycle dysfunction have improved, chronic complications, such as liver disease, have become increasingly apparent in individuals with UCDs. Liver disease in UCDs may be associated with hepatic inflammation, hepatic fibrosis, portal hypertension, liver cancer and even liver failure. However, except for monitoring serum aminotransferases, there are no clear guidelines for screening and/or monitoring individuals with UCDs for liver disease. Thus, we systematically evaluated the potential utility of several non-invasive biomarkers for liver fibrosis in UCDs. METHODS We evaluated grey-scale ultrasonography, liver stiffness obtained from shear wave elastography (SWE), and various serum biomarkers for hepatic fibrosis and necroinflammation, in a cohort of 28 children and adults with various UCDs. RESULTS Overall, we demonstrate a high burden of liver disease in our participants with 46% of participants having abnormal grey-scale ultrasound pattern of the liver parenchyma, and 52% of individuals having increased liver stiffness. The analysis of serum biomarkers revealed that 32% of participants had elevated FibroTest™ score, a marker for hepatic fibrosis, and 25% of participants had increased ActiTest™ score, a marker for necroinflammation. Interestingly, liver stiffness did not correlate with ultrasound appearance or FibroTest™. CONCLUSION Overall, our results demonstrate the high overall burden of liver disease in UCDs and highlights the need for further studies exploring new tools for identifying and monitoring individuals with UCDs who are at risk for this complication. TRIAL REGISTRATION This study has been registered in ClinicalTrials.gov (NCT03721367).
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MESH Headings
- Adolescent
- Adult
- Argininosuccinate Lyase/blood
- Biomarkers/blood
- Child
- Child, Preschool
- Elasticity Imaging Techniques
- Female
- Genetic Diseases, Inborn/blood
- Genetic Diseases, Inborn/diagnostic imaging
- Genetic Diseases, Inborn/genetics
- Genetic Diseases, Inborn/pathology
- Humans
- Hyperammonemia/blood
- Hyperammonemia/genetics
- Hyperammonemia/metabolism
- Hyperammonemia/pathology
- Liver/diagnostic imaging
- Liver/pathology
- Liver Cirrhosis/blood
- Liver Cirrhosis/diagnostic imaging
- Liver Cirrhosis/genetics
- Liver Cirrhosis/pathology
- Liver Diseases/blood
- Liver Diseases/genetics
- Liver Diseases/metabolism
- Liver Diseases/pathology
- Male
- Metabolism, Inborn Errors/genetics
- Middle Aged
- Ultrasonography
- Urea Cycle Disorders, Inborn/blood
- Urea Cycle Disorders, Inborn/genetics
- Urea Cycle Disorders, Inborn/metabolism
- Urea Cycle Disorders, Inborn/pathology
- Young Adult
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Affiliation(s)
- Sandesh C S Nagamani
- Department of Molecular & Human Genetics, Baylor College of Medicine, Houston, TX, USA; Texas Children's Hospital, Houston, TX, USA
| | - Saima Ali
- Department of Molecular & Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Rima Izem
- Division of Biostatistics and Study Methodology, Children's National Research Institute, Silver Spring, MD, USA; Department of Pediatrics, George Washington University, Washington, DC, USA; Department of Epidemiology, George Washington University, Washington, DC, USA
| | - Deborah Schady
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA
| | - Prakash Masand
- Texas Children's Hospital, Houston, TX, USA; Edward B. Singleton Department of Radiology, Texas Children's Hospital, Houston, TX 77030, USA
| | - Benjamin L Shneider
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; Pediatric Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Houston, TX, USA
| | - Daniel H Leung
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; Pediatric Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Houston, TX, USA
| | - Lindsay C Burrage
- Department of Molecular & Human Genetics, Baylor College of Medicine, Houston, TX, USA; Texas Children's Hospital, Houston, TX, USA.
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14
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Sugahara G, Yamasaki C, Yanagi A, Furukawa S, Ogawa Y, Fukuda A, Enosawa S, Umezawa A, Ishida Y, Tateno C. Humanized liver mouse model with transplanted human hepatocytes from patients with ornithine transcarbamylase deficiency. J Inherit Metab Dis 2021; 44:618-628. [PMID: 33336822 PMCID: PMC8247293 DOI: 10.1002/jimd.12347] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 12/10/2020] [Accepted: 12/16/2020] [Indexed: 12/20/2022]
Abstract
Ornithine transcarbamylase deficiency (OTCD) is a metabolic and genetic disease caused by dysfunction of the hepatocytic urea cycle. To develop new drugs or therapies for OTCD, it is ideal to use models that are more closely related to human metabolism and pathology. Primary human hepatocytes (HHs) isolated from two patients (a 6-month-old boy and a 5-year-old girl) and a healthy donor were transplanted into host mice (hemi-, hetero-OTCD mice, and control mice, respectively). HHs were isolated from these mice and used for serial transplantation into the next host mouse or for in vitro experiments. Histological, biochemical, and enzyme activity analyses were performed. Cultured HHs were treated with ammonium chloride or therapeutic drugs. Replacement rates exceeded 80% after serial transplantation in both OTCD mice. These highly humanized OTCD mice showed characteristics similar to OTCD patients that included increased blood ammonia levels and urine orotic acid levels enhanced by allopurinol. Hemi-OTCD mice showed defects in OTC expression and significantly low enzymatic activities, while hetero-OTCD mice showed residual OTC expression and activities. A reduction in ammonium metabolism was observed in cultured HHs from OTCD mice, and treatment with the therapeutic drug reduced the ammonia levels in the culture medium. In conclusion, we established in vivo OTC mouse models with hemi- and hetero-patient HHs. HHs isolated from the mice were useful as an in vitro model of OTCD. These OTC models could be a source of valuable patient-derived hepatocytes that would enable large scale and reproducible experiments using the same donor.
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Affiliation(s)
- Go Sugahara
- Research and Development DepartmentPhoenixBio Co., LtdHigashi‐HiroshimaJapan
| | - Chihiro Yamasaki
- Research and Development DepartmentPhoenixBio Co., LtdHigashi‐HiroshimaJapan
| | - Ami Yanagi
- Research and Development DepartmentPhoenixBio Co., LtdHigashi‐HiroshimaJapan
| | - Suzue Furukawa
- Research and Development DepartmentPhoenixBio Co., LtdHigashi‐HiroshimaJapan
| | - Yuko Ogawa
- Research and Development DepartmentPhoenixBio Co., LtdHigashi‐HiroshimaJapan
| | - Akinari Fukuda
- National Center for Child Health and DevelopmentTokyoJapan
| | - Shin Enosawa
- Division for Advanced Medical SciencesNational Center for Child Health and DevelopmentTokyoJapan
| | - Akihiro Umezawa
- Regenerative MedicineNational Center for Child Health and DevelopmentTokyoJapan
| | - Yuji Ishida
- Research and Development DepartmentPhoenixBio Co., LtdHigashi‐HiroshimaJapan
- Research Center for Hepatology and GastroenterologyHiroshima UniversityHiroshimaJapan
| | - Chise Tateno
- Research and Development DepartmentPhoenixBio Co., LtdHigashi‐HiroshimaJapan
- Research Center for Hepatology and GastroenterologyHiroshima UniversityHiroshimaJapan
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15
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Rudler M, Weiss N, Bouzbib C, Thabut D. Diagnosis and Management of Hepatic Encephalopathy. Clin Liver Dis 2021; 25:393-417. [PMID: 33838857 DOI: 10.1016/j.cld.2021.01.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Hepatic encephalopathy (HE) is a severe complication of cirrhosis. The prevalence of overt HE (OHE) ranges from 30% to 45%, whereas the prevalence of minimal HE (MHE) is as high as 85% in some case series. Widespread use of transjugular intrahepatic portosystemic shunt to control complications related to portal hypertension is associated with an increase in HE incidence. If the diagnosis of OHE remains simple in most cases, then the diagnosis of MHE is less codified because of many differential diagnoses with different therapeutic implications. This review analyzes current knowledge about the pathophysiology, diagnosis, and different therapeutic options of HE.
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Affiliation(s)
- Marika Rudler
- Brain Liver Salpêtrière Study Group, Sorbonne Université, INSERM UMR_S 938, Centre de Recherche Saint-Antoine & Institute of Cardiometabolism and Nutrition (ICAN), Paris 75013, France; AP-HP, Sorbonne Université, Liver Intensive Care Unit, Hepatogastroenterology Department, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, Paris 75013, France
| | - Nicolas Weiss
- Brain Liver Salpêtrière Study Group, Sorbonne Université, INSERM UMR_S 938, Centre de Recherche Saint-Antoine & Institute of Cardiometabolism and Nutrition (ICAN), Paris 75013, France; AP-HP, Sorbonne Université, Neurological Intensive Care Unit, Neurology Department, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, Paris 75013, France; Sorbonne Université, Paris F-75005, France
| | - Charlotte Bouzbib
- Brain Liver Salpêtrière Study Group, Sorbonne Université, INSERM UMR_S 938, Centre de Recherche Saint-Antoine & Institute of Cardiometabolism and Nutrition (ICAN), Paris 75013, France; AP-HP, Sorbonne Université, Liver Intensive Care Unit, Hepatogastroenterology Department, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, Paris 75013, France
| | - Dominique Thabut
- Brain Liver Salpêtrière Study Group, Sorbonne Université, INSERM UMR_S 938, Centre de Recherche Saint-Antoine & Institute of Cardiometabolism and Nutrition (ICAN), Paris 75013, France; AP-HP, Sorbonne Université, Liver Intensive Care Unit, Hepatogastroenterology Department, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, Paris 75013, France; Sorbonne Université, Paris F-75005, France.
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16
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Regan JT, Mirczuk SM, Scudder CJ, Stacey E, Khan S, Worwood M, Powles T, Dennis-Beron JS, Ginley-Hidinger M, McGonnell IM, Volk HA, Strickland R, Tivers MS, Lawson C, Lipscomb VJ, Fowkes RC. Sensitivity of the Natriuretic Peptide/cGMP System to Hyperammonaemia in Rat C6 Glioma Cells and GPNT Brain Endothelial Cells. Cells 2021; 10:cells10020398. [PMID: 33672024 PMCID: PMC7919485 DOI: 10.3390/cells10020398] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 02/05/2021] [Accepted: 02/11/2021] [Indexed: 12/16/2022] Open
Abstract
C-type natriuretic peptide (CNP) is the major natriuretic peptide of the central nervous system and acts via its selective guanylyl cyclase-B (GC-B) receptor to regulate cGMP production in neurons, astrocytes and endothelial cells. CNP is implicated in the regulation of neurogenesis, axonal bifurcation, as well as learning and memory. Several neurological disorders result in toxic concentrations of ammonia (hyperammonaemia), which can adversely affect astrocyte function. However, the relationship between CNP and hyperammonaemia is poorly understood. Here, we examine the molecular and pharmacological control of CNP in rat C6 glioma cells and rat GPNT brain endothelial cells, under conditions of hyperammonaemia. Concentration-dependent inhibition of C6 glioma cell proliferation by hyperammonaemia was unaffected by CNP co-treatment. Furthermore, hyperammonaemia pre-treatment (for 1 h and 24 h) caused a significant inhibition in subsequent CNP-stimulated cGMP accumulation in both C6 and GPNT cells, whereas nitric-oxide-dependent cGMP accumulation was not affected. CNP-stimulated cGMP efflux from C6 glioma cells was significantly reduced under conditions of hyperammonaemia, potentially via a mechanism involving changed in phosphodiesterase expression. Hyperammonaemia-stimulated ROS production was unaffected by CNP but enhanced by a nitric oxide donor in C6 cells. Extracellular vesicle production from C6 cells was enhanced by hyperammonaemia, and these vesicles caused impaired CNP-stimulated cGMP signalling in GPNT cells. Collectively, these data demonstrate functional interaction between CNP signalling and hyperammonaemia in C6 glioma and GPNT cells, but the exact mechanisms remain to be established.
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Affiliation(s)
- Jacob T. Regan
- Endocrine Signalling Group, Department of Comparative Biomedical Sciences, The Royal Veterinary College, University of London, Royal College Street, London NW1 0TU, UK; (J.T.R.); (S.M.M.); (C.J.S.); (E.S.); (S.K.); (M.W.); (T.P.); (J.S.D.-B.); (M.G.-H.)
| | - Samantha M. Mirczuk
- Endocrine Signalling Group, Department of Comparative Biomedical Sciences, The Royal Veterinary College, University of London, Royal College Street, London NW1 0TU, UK; (J.T.R.); (S.M.M.); (C.J.S.); (E.S.); (S.K.); (M.W.); (T.P.); (J.S.D.-B.); (M.G.-H.)
- Department of Comparative Biomedical Sciences, The Royal Veterinary College, University of London, Royal College Street, London NW1 0TU, UK; (I.M.M.); (C.L.)
| | - Christopher J. Scudder
- Endocrine Signalling Group, Department of Comparative Biomedical Sciences, The Royal Veterinary College, University of London, Royal College Street, London NW1 0TU, UK; (J.T.R.); (S.M.M.); (C.J.S.); (E.S.); (S.K.); (M.W.); (T.P.); (J.S.D.-B.); (M.G.-H.)
- Department of Comparative Biomedical Sciences, The Royal Veterinary College, University of London, Royal College Street, London NW1 0TU, UK; (I.M.M.); (C.L.)
| | - Emily Stacey
- Endocrine Signalling Group, Department of Comparative Biomedical Sciences, The Royal Veterinary College, University of London, Royal College Street, London NW1 0TU, UK; (J.T.R.); (S.M.M.); (C.J.S.); (E.S.); (S.K.); (M.W.); (T.P.); (J.S.D.-B.); (M.G.-H.)
| | - Sabah Khan
- Endocrine Signalling Group, Department of Comparative Biomedical Sciences, The Royal Veterinary College, University of London, Royal College Street, London NW1 0TU, UK; (J.T.R.); (S.M.M.); (C.J.S.); (E.S.); (S.K.); (M.W.); (T.P.); (J.S.D.-B.); (M.G.-H.)
| | - Michael Worwood
- Endocrine Signalling Group, Department of Comparative Biomedical Sciences, The Royal Veterinary College, University of London, Royal College Street, London NW1 0TU, UK; (J.T.R.); (S.M.M.); (C.J.S.); (E.S.); (S.K.); (M.W.); (T.P.); (J.S.D.-B.); (M.G.-H.)
| | - Torinn Powles
- Endocrine Signalling Group, Department of Comparative Biomedical Sciences, The Royal Veterinary College, University of London, Royal College Street, London NW1 0TU, UK; (J.T.R.); (S.M.M.); (C.J.S.); (E.S.); (S.K.); (M.W.); (T.P.); (J.S.D.-B.); (M.G.-H.)
| | - J. Sebastian Dennis-Beron
- Endocrine Signalling Group, Department of Comparative Biomedical Sciences, The Royal Veterinary College, University of London, Royal College Street, London NW1 0TU, UK; (J.T.R.); (S.M.M.); (C.J.S.); (E.S.); (S.K.); (M.W.); (T.P.); (J.S.D.-B.); (M.G.-H.)
| | - Matthew Ginley-Hidinger
- Endocrine Signalling Group, Department of Comparative Biomedical Sciences, The Royal Veterinary College, University of London, Royal College Street, London NW1 0TU, UK; (J.T.R.); (S.M.M.); (C.J.S.); (E.S.); (S.K.); (M.W.); (T.P.); (J.S.D.-B.); (M.G.-H.)
| | - Imelda M. McGonnell
- Department of Comparative Biomedical Sciences, The Royal Veterinary College, University of London, Royal College Street, London NW1 0TU, UK; (I.M.M.); (C.L.)
| | - Holger A. Volk
- Stiftung Tierärztliche Hochschule Hannover, Klinik für Kleintiere, Bünteweg, 930559 Hannover, Germany;
| | - Rhiannon Strickland
- Clinical Sciences & Services, Hawkshead Lane, North Mymms, Hatfield, Hertfordshire AL9 7TA, UK; (R.S.); (V.J.L.)
| | - Michael S. Tivers
- Paragon Veterinary Referrals, Paragon Business Village Paragon Way, Red Hall Cres, Wakefield WF1 2DF, UK;
| | - Charlotte Lawson
- Department of Comparative Biomedical Sciences, The Royal Veterinary College, University of London, Royal College Street, London NW1 0TU, UK; (I.M.M.); (C.L.)
| | - Victoria J. Lipscomb
- Clinical Sciences & Services, Hawkshead Lane, North Mymms, Hatfield, Hertfordshire AL9 7TA, UK; (R.S.); (V.J.L.)
| | - Robert C. Fowkes
- Endocrine Signalling Group, Department of Comparative Biomedical Sciences, The Royal Veterinary College, University of London, Royal College Street, London NW1 0TU, UK; (J.T.R.); (S.M.M.); (C.J.S.); (E.S.); (S.K.); (M.W.); (T.P.); (J.S.D.-B.); (M.G.-H.)
- Department of Comparative Biomedical Sciences, The Royal Veterinary College, University of London, Royal College Street, London NW1 0TU, UK; (I.M.M.); (C.L.)
- Correspondence: ; Tel.: +44-207-468-1215
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17
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Clarkston K, Lee J, Donoghue S, Peters H, Eiroa H, Shah AA, Loomes K, Wen J, Oliver M, Hardikar W, Prada CE, Asai A. Acute liver dysfunction with delayed peak of serum aminotransferase levels as a presentation of ornithine transcarbamylase deficiency in females. Am J Med Genet A 2020; 185:909-915. [PMID: 33369132 DOI: 10.1002/ajmg.a.62031] [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: 08/04/2020] [Revised: 11/04/2020] [Accepted: 11/27/2020] [Indexed: 11/11/2022]
Abstract
We describe 10 females with ornithine transcarbamylase (OTC) deficiency and liver dysfunction, revealing a unique pattern of hepatocyte injury in which initial hyperammonemia and coagulopathy is followed by a delayed peak in aminotransferase levels. None of the patients required urgent liver transplantation, though five eventually underwent transplant for recurrent metabolic crises. We intend that this novel observation will initiate further investigations into the pathophysiology of liver dysfunction in OTC-deficient patients, and ultimately lead to the development of therapies and prevent the need for liver transplant.
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Affiliation(s)
- Kathryn Clarkston
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Joy Lee
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Metabolic Medicine, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Sarah Donoghue
- Department of Metabolic Medicine, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Heidi Peters
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Metabolic Medicine, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Hernan Eiroa
- Servicio de Errores Congenitos del Metabolismo, Hospital de Pediatria "J.P.Garrahan", Buenos Aires, Argentina
| | - Amit A Shah
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kathleen Loomes
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jessica Wen
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mark Oliver
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Gastroenterology, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Winita Hardikar
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Gastroenterology, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Carlos E Prada
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Akihiro Asai
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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18
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A novel splice site mutation in OTC gene of a female with ornithine transcarbamylase deficiency and her asymptomatic mosaic father. J Genet 2020. [DOI: 10.1007/s12041-020-1189-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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19
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Yamasaki C, Ishida Y, Yanagi A, Yoshizane Y, Kojima Y, Ogawa Y, Kageyama Y, Iwasaki Y, Ishida S, Chayama K, Tateno C. Culture density contributes to hepatic functions of fresh human hepatocytes isolated from chimeric mice with humanized livers: Novel, long-term, functional two-dimensional in vitro tool for developing new drugs. PLoS One 2020; 15:e0237809. [PMID: 32915792 PMCID: PMC7485858 DOI: 10.1371/journal.pone.0237809] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 08/03/2020] [Indexed: 01/25/2023] Open
Abstract
Chimeric mice with humanized livers are considered a useful animal model for predicting human (h-) drug metabolism and toxicity. In this study, the characteristics of fresh h-hepatocytes (cFHHs, PXB-cells®) isolated from chimeric mice (PXB-mice®) were evaluated in vitro to confirm their utility for drug development. cFHHs cultured at high density (2.13 × 105 cells/cm2) displayed stable production of h-albumin and cytochrome P450 (CYP) 3A activities for at least 21 days. The mRNA expression levels of 10 of 13 CYP, UDP-glucuronosyltransferase (UGT), and transporters were maintained at >10% of the levels of freshly isolated cFHHs after 21 days. From 1 week, many bile canaliculi were observed between cFHHs, and the accumulation of the multidrug resistance-associated protein and bile salt export pump substrates in these bile canaliculi was clearly inhibited by cyclosporin A. Microarray analysis of cFHHs cultured at high density and at low density (0.53 × 105 cells/cm2) revealed that high density culture maintained high expressions of some transcription factors (HNF4α, PXR, and FXR) perhaps involved in the high CYP, UGT and transporter gene expressions of cFHHs. These results strongly suggest that cFHHs could be a novel in vitro tool for drug development studies.
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Affiliation(s)
| | - Yuji Ishida
- PhoenixBio Co., Ltd., Higashi-Hiroshima, Hiroshima, Japan
- Research Center for Hepatology and Gastroenterology, Hiroshima University, Hiroshima, Japan
| | - Ami Yanagi
- PhoenixBio Co., Ltd., Higashi-Hiroshima, Hiroshima, Japan
| | | | - Yuha Kojima
- PhoenixBio Co., Ltd., Higashi-Hiroshima, Hiroshima, Japan
| | - Yuko Ogawa
- PhoenixBio Co., Ltd., Higashi-Hiroshima, Hiroshima, Japan
| | | | - Yumiko Iwasaki
- PhoenixBio Co., Ltd., Higashi-Hiroshima, Hiroshima, Japan
| | - Seiichi Ishida
- Department of Pharmacology, National Institute of Health Sciences, Kanagawa, Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Higashihiroshima, Hiroshima, Japan
| | - Chise Tateno
- PhoenixBio Co., Ltd., Higashi-Hiroshima, Hiroshima, Japan
- Research Center for Hepatology and Gastroenterology, Hiroshima University, Hiroshima, Japan
- * E-mail:
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20
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Ornithine Transcarbamylase Deficiency Presenting as Acute Liver Failure in Girls: A Paediatric Case Series. J Pediatr Gastroenterol Nutr 2020; 71:208-210. [PMID: 32265410 DOI: 10.1097/mpg.0000000000002716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Ornithine transcarbamylase deficiency (OTCD) is the most common of the urea cycle disorders and follows an X-linked inheritance pattern. The classical form in male infants causes vomiting and lethargy in the neonatal period; if untreated the severe hyperammonaemia can cause acute neurotoxic complications and permanent disability. OTCD may also occur in heterozygote female individuals, though the manifestations are variable. We report 2 cases of female paediatric patients with OTCD, who presented with acute liver failure. Both patients had limited oral intake at the time of presentation, causing an absence of orotic aciduria, which delayed the diagnosis. These cases demonstrate the need to consider urea cycle disorders in children presenting with acute liver failure, and that repeating the urine metabolic screen at the time of an unrestricted diet is warranted if there is a high clinical suspicion.
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21
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Clinical and biochemical characteristics of patients with ornithine transcarbamylase deficiency. Clin Biochem 2020; 84:63-72. [PMID: 32569589 DOI: 10.1016/j.clinbiochem.2020.06.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 05/31/2020] [Accepted: 06/16/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Ornithine transcarbamylase deficiency (OTCD) is pleomorphic congenital hyperammonemia, in which the prognosis of the patient is determined both by genotype and environmental factors. This study investigated the clinical and biochemical characteristics of OTCD patients with different prognosis. METHOD Of 35 OTCD patients, six males deceased at the first disease-onset, 17 males survived and had controllable ammonia levels after treatment, and 12 females survived through the first disease-onset but had intractable hyperammonemia and high mortality. Fasting blood samples from patients collected at three disease stages were used for the analysis of amino acid (AA) profile, acylcarnitine profile, and micronutrients. Differences in profiles between patients and healthy controls and within patient groups were studied. RESULTS All OTCD patients had accumulation of glutamine, homocitrulline, lysine, glutamate, cystathionine, and pipecolic acid, as well as deficiency of citrulline, tryptophan, threonine, and carnitine. For male non-survivors, most other AAs and long-chain acylcarnitines were elevated at disease onset, of which the levels of creatine, N-acetylaspartic acid, and homoarginine were remarkably high. Male survivors and female patients had most other AAs at low to normal levels. Compared with male survivors, female patients had much lower protein-intolerance, as indicated by significantly lower levels of protein consumption indicators, including essential AAs, 1-methylhistidine, acylcarnitines et al., but high levels of ammonia. Female patients still had significantly higher levels of citrulline, homocitrulline, and citrulline/arginine compared to male survivors. CONCLUSION Unique profiles were observed in each group of OTCD patients, indicating specific physiological changes that happened to them.
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22
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Coban MA, Fraga S, Caulfield TR. Structural And Computational Perspectives of Selectively Targeting Mutant Proteins. Curr Drug Discov Technol 2020; 18:365-378. [PMID: 32160847 DOI: 10.2174/1570163817666200311114819] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/24/2020] [Accepted: 01/28/2020] [Indexed: 11/22/2022]
Abstract
Diseases are often caused by mutant proteins. Many drugs have limited effectiveness and/or toxic side effects because of a failure to selectively target the disease-causing mutant variant, rather than the functional wild type protein. Otherwise, the drugs may even target different proteins with similar structural features. Designing drugs that successfully target mutant proteins selectively represents a major challenge. Decades of cancer research have led to an abundance of potential therapeutic targets, often touted to be "master regulators". For many of these proteins, there are no FDA-approved drugs available; for others, off-target effects result in dose-limiting toxicity. Cancer-related proteins are an excellent medium to carry the story of mutant-specific targeting, as the disease is both initiated and sustained by mutant proteins; furthermore, current chemotherapies generally fail at adequate selective distinction. This review discusses some of the challenges associated with selective targeting from a structural biology perspective, as well as some of the developments in algorithm approach and computational workflow that can be applied to address those issues. One of the most widely researched proteins in cancer biology is p53, a tumor suppressor. Here, p53 is discussed as a specific example of a challenging target, with contemporary drugs and methodologies used as examples of burgeoning successes. The oncogene KRAS, which has been described as "undruggable", is another extensively investigated protein in cancer biology. This review also examines KRAS to exemplify progress made towards selective targeting of diseasecausing mutant proteins. Finally, possible future directions relevant to the topic are discussed.
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Affiliation(s)
- Mathew A Coban
- Department of Cancer Biology, Mayo Clinic, Jacksonville, FL, 32224, United States
| | - Sarah Fraga
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, 32224, United States
| | - Thomas R Caulfield
- Department of Cancer Biology, Mayo Clinic, Jacksonville, FL, 32224, United States
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23
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Burrage LC, Madan S, Li X, Ali S, Mohammad M, Stroup BM, Jiang MM, Cela R, Bertin T, Jin Z, Dai J, Guffey D, Finegold M, Nagamani S, Minard CG, Marini J, Masand P, Schady D, Shneider BL, Leung DH, Bali D, Lee B. Chronic liver disease and impaired hepatic glycogen metabolism in argininosuccinate lyase deficiency. JCI Insight 2020; 5:132342. [PMID: 31990680 PMCID: PMC7101134 DOI: 10.1172/jci.insight.132342] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 01/15/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUNDLiver disease in urea cycle disorders (UCDs) ranges from hepatomegaly and chronic hepatocellular injury to cirrhosis and end-stage liver disease. However, the prevalence and underlying mechanisms are unclear.METHODSWe estimated the prevalence of chronic hepatocellular injury in UCDs using data from a multicenter, longitudinal, natural history study. We also used ultrasound with shear wave elastography and FibroTest to evaluate liver stiffness and markers of fibrosis in individuals with argininosuccinate lyase deficiency (ASLD), a disorder with high prevalence of elevated serum alanine aminotransferase (ALT). To understand the human observations, we evaluated the hepatic phenotype of the AslNeo/Neo mouse model of ASLD.RESULTSWe demonstrate a high prevalence of elevated ALT in ASLD (37%). Hyperammonemia and use of nitrogen-scavenging agents, 2 markers of disease severity, were significantly (P < 0.001 and P = 0.001, respectively) associated with elevated ALT in ASLD. In addition, ultrasound with shear wave elastography and FibroTest revealed increased echogenicity and liver stiffness, even in individuals with ASLD and normal aminotransferases. The AslNeo/Neo mice mimic the human disorder with hepatomegaly, elevated aminotransferases, and excessive hepatic glycogen noted before death (3-5 weeks of age). This excessive hepatic glycogen is associated with impaired hepatic glycogenolysis and decreased glycogen phosphorylase and is rescued with helper-dependent adenovirus expressing Asl using a liver-specific (ApoE) promoter.CONCLUSIONOur results link urea cycle dysfunction and impaired hepatic glucose metabolism and identify a mouse model of liver disease in the setting of urea cycle dysfunction.TRIAL REGISTRATIONThis study has been registered at ClinicalTrials.gov (NCT03721367, NCT00237315).FUNDINGFunding was provided by NIH, Burroughs Wellcome Fund, NUCDF, Genzyme/ACMG Foundation, and CPRIT.
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Affiliation(s)
- Lindsay C. Burrage
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA
- Texas Children’s Hospital, Houston, Texas, USA
| | - Simran Madan
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA
- Interdepartmental Program in Translational Biology and Molecular Medicine and
| | - Xiaohui Li
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA
| | - Saima Ali
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA
| | - Mahmoud Mohammad
- USDA/ARS Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Department of Food Science and Nutrition, National Research Centre, Dokki, Giza, Egypt
| | - Bridget M. Stroup
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA
| | - Ming-Ming Jiang
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA
| | - Racel Cela
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA
| | - Terry Bertin
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA
| | - Zixue Jin
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA
| | - Jian Dai
- Department of Pediatrics, Duke Health, Durham, North Carolina, USA
| | - Danielle Guffey
- Dan L. Duncan Institute for Clinical and Translational Research and
| | - Milton Finegold
- Department of Pathology, Baylor College of Medicine, Houston, Texas, USA
| | | | - Sandesh Nagamani
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA
- Texas Children’s Hospital, Houston, Texas, USA
| | | | - Juan Marini
- USDA/ARS Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Prakash Masand
- Edward B. Singleton Department of Pediatric Radiology, Texas Children’s Hospital, Houston, Texas, USA
| | - Deborah Schady
- Department of Pathology, Baylor College of Medicine, Houston, Texas, USA
| | - Benjamin L. Shneider
- Texas Children’s Hospital, Houston, Texas, USA
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel H. Leung
- Texas Children’s Hospital, Houston, Texas, USA
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, Texas, USA
| | - Deeksha Bali
- Department of Pediatrics, Duke Health, Durham, North Carolina, USA
| | - Brendan Lee
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA
- Texas Children’s Hospital, Houston, Texas, USA
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24
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Nguyen HH, Khanh Nguyen N, Dung Vu C, Thu Huong Nguyen T, Nguyen NL. Late-Onset Ornithine Transcarbamylase Deficiency and Variable Phenotypes in Vietnamese Females With OTC Mutations. Front Pediatr 2020; 8:321. [PMID: 32793520 PMCID: PMC7390877 DOI: 10.3389/fped.2020.00321] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 05/18/2020] [Indexed: 12/22/2022] Open
Abstract
Background: Ornithine transcarbamylase deficiency (OTCD) is an X- linked recessive disorder and the most common error of the urea cycle, caused by the mutations in the OTC gene. Due to X-inactivation, 15-20% of female carriers present symptoms of OTCD at late onset. Early diagnosis of OTCD by molecular analysis in females is highly desirable. The aim of the study was to identify the mutations in two unrelated Vietnamese girls suspected with OTCD and the carriers in their families for definitive diagnosis and proper counseling. Case Presentation: Two patients presented with an acute encephalopathy at the first admission. Biochemical tests revealed hyperammonemia, hyperlactatemia, elevated glutamine level, elevated transaminase, elevated urinary orotic and uracil acid levels, and disorder of prothrombin time. Brain magnetic resonance imaging indicated cerebral edema. Based on the clinical and laboratory results, the two patients were diagnosed with urea cycle disorders. Therefore, the two patients were managed by stopping feeding, with infused glucose, l-carnitine, l-arginine, and sodium benzoate, and with hemofiltration. The two patients were alert and recovered with normal blood ammonia levels after 72 h of treatment. The family history of patient 1 showed that her brother died at 4 days of age due to a coma and dyspnea, while her parents were asymptomatic. Variable phenotypes were observed in three generations of the patient 2's family, including asymptomatic (mother), affected female adults dying at the first symptom (grandmother and aunt), and affected males dying in the first week of life (uncle, cousin, and siblings). Whole-exome sequencing showed two mutations in the OTC gene, including one novel missense mutation, c.365A>T, in the patient 1 and one previously reported splicing mutation, c.717+1G>A, in the patient 2. The two mutations are evaluated as likely pathogenic and pathogenic, respectively, according to the recommendations of the American College of Medical Genetics and Genomics (ACMG). Genetic analyses in the families indicated the mothers were heterozygous. Conclusion: Clinical, biochemical, and molecular findings accurately diagnosed the two patients with late-onset OTCD. Our results explained the genetic causes and proposed the risk in the patients' families, which could be useful for genetic counseling and monitoring in prenatal diagnosis.
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Affiliation(s)
- Huy-Hoang Nguyen
- Institute of Genome Research, Vietnam Academy of Science and Technology (VAST), Hanoi, Vietnam
| | - Ngoc Khanh Nguyen
- Department of Endocrinology, Metabolism and Genetic, Center for Rare Diseases and Newborn Screening, Vietnam National Hospital of Pediatrics, Hanoi, Vietnam
| | - Chi Dung Vu
- Department of Endocrinology, Metabolism and Genetic, Center for Rare Diseases and Newborn Screening, Vietnam National Hospital of Pediatrics, Hanoi, Vietnam
| | - Thi Thu Huong Nguyen
- Institute of Genome Research, Vietnam Academy of Science and Technology (VAST), Hanoi, Vietnam.,Graduate University of Science and Technology, Vietnam Academy of Science and Technology (VAST), Hanoi, Vietnam
| | - Ngoc-Lan Nguyen
- Institute of Genome Research, Vietnam Academy of Science and Technology (VAST), Hanoi, Vietnam.,Graduate University of Science and Technology, Vietnam Academy of Science and Technology (VAST), Hanoi, Vietnam
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25
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Ranucci G, Rigoldi M, Cotugno G, Bernabei SM, Liguori A, Gasperini S, Goffredo BM, Martinelli D, Monti L, Francalanci P, Candusso M, Parini R, Dionisi-Vici C. Chronic liver involvement in urea cycle disorders. J Inherit Metab Dis 2019; 42:1118-1127. [PMID: 31260111 DOI: 10.1002/jimd.12144] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 06/21/2019] [Accepted: 06/28/2019] [Indexed: 12/15/2022]
Abstract
The increased survival of urea cycle disorders (UCDs) patients has led the attention to clinical manifestations that characterize the long-term disease course. Acute and chronic liver disease have been anecdotally reported since the very first description of UCDs. However, a detailed analysis of long-term liver involvement in large patient cohorts is still needed. Chronic liver damage in UCDs has probably a multifactorial origin, but the specific underlying mechanisms of liver disease have not yet been well elucidated. In this study, we report on chronic liver involvement and on associated metabolic abnormalities in a large cohort of 102 UCD patients, followed by two reference centers in Italy. Chronic liver involvement was observed in over 60% of UCDs patients, and comparison between individual diseases showed a significant higher frequency in argininosuccinate lyase deficiency (ASLD) and in hyperornithinemia-hyperammonemia-homocitrullinemia (HHH) syndrome with elevation of transaminases and of gamma-GT in ASLD, and of alpha-fetoprotein in HHH syndrome. Also, consistent with a chronic hepatic dysfunction, ultrasound examination revealed more pronounced abnormalities in ASLD and in HHH syndrome, when compared to other UCDs. Our study highlights in a large UCDs patients' cohort that chronic liver disease is a common finding in UCDs, often with a distinct phenotype between different diseases. Furthers studies are needed to elucidate the specific involvement of different metabolic pathways in the pathogenesis of liver dysfunction in UCDs.
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Affiliation(s)
- Giusy Ranucci
- Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Miriam Rigoldi
- Medical Genetics Unit, Rare Diseases Center, ASST San Gerardo Hospital, Monza, Italy
| | - Giovanna Cotugno
- Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Silvia Maria Bernabei
- Division of Artificial Nutrition, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alessandra Liguori
- Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Serena Gasperini
- Pediatric Rare Diseases Unit, Department of Pediatrics, MBBM Foundation, ATS Monza e Brianza, Monza, Italy
| | | | - Diego Martinelli
- Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Lidia Monti
- Department of Radiology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paola Francalanci
- Department of Pathology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Manila Candusso
- Division of Hepatology and Gastroenterology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Rossella Parini
- Pediatric Rare Diseases Unit, Department of Pediatrics, MBBM Foundation, ATS Monza e Brianza, Monza, Italy
| | - Carlo Dionisi-Vici
- Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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26
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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: 249] [Impact Index Per Article: 49.8] [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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27
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Stepien KM, Geberhiwot T, Hendriksz CJ, Treacy EP. Challenges in diagnosing and managing adult patients with urea cycle disorders. J Inherit Metab Dis 2019; 42:1136-1146. [PMID: 30932189 DOI: 10.1002/jimd.12096] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 03/28/2019] [Indexed: 12/15/2022]
Abstract
Urea cycle disorders (UCD) are a group of rare inherited metabolic conditions of amino acid catabolism caused by an enzyme deficiency within the hepatic ammonia detoxification pathway. The presentation of these disorders ranges from life-threatening intoxication in the neonate to asymptomatic status in adults. Late-onset UCDs can present for the first time in adulthood and may mimic other causes of acute confusion or psychiatric diseases, and are often associated with neurological symptoms. Late-onset UCDs may become apparent during periods of metabolic stress such as rapid weight loss, gastric bypass surgery, chronic starvation or the postpartum period. Early diagnosis is critical for effective treatment and to prevent long-term complications of hyperammonemia. The challenges of management of adults include for example: (a) poor compliance to dietary and medical treatment which can result in recurrent hospital admissions; (b) severe neurological dysfunction; (c) the management of pregnancy and the postpartum period; and (d) access to multidisciplinary care peri-operatively. In this review, we highlight a number of challenges in the diagnosis and management of adult patient with late-onset UCDs and suggest a systematic management approach.
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Affiliation(s)
- Karolina M Stepien
- Mark Holland Metabolic Unit, Adult Inherited Metabolic Diseases Department, Salford Royal NHS Foundation Trust, Salford, UK
| | - Tarekegn Geberhiwot
- Centre for Endocrinology, Diabetes and Metabolism, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Christian J Hendriksz
- Department of Paediatrics, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
| | - Eileen P Treacy
- National Centre for Inherited Metabolic Diseases, The Mater Misericordiae University Hospital, Dublin, Ireland
- Department of Paediatrics, Trinity College, Dublin, Ireland
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28
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Sharifi F, Firoozabadi B, Firoozbakhsh K. Numerical Investigations of Hepatic Spheroids Metabolic Reactions in a Perfusion Bioreactor. Front Bioeng Biotechnol 2019; 7:221. [PMID: 31572719 PMCID: PMC6751279 DOI: 10.3389/fbioe.2019.00221] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 08/28/2019] [Indexed: 12/20/2022] Open
Abstract
Miniaturized culture systems of hepatic cells are emerging as a strong tool facilitating studies related to liver diseases and drug discovery. However, the experimental optimization of various parameters involved in the operation of these systems is time-consuming and expensive. Hence, developing numerical tools predicting the function of such systems can significantly reduce the associated cost. In this paper, a perfusion-based three dimensional (3D) bioreactor comprising encapsulated human liver hepatocellular carcinoma (HepG2) spheroids are analyzed. The flow and mass transfer equations for oxygen as well as different metabolites such as albumin, glucose, glutamine, ammonia, and urea were solved in three different domains, i.e., free flow, hydrogel, and spheroid porous media sections. Since the spheroids were encapsulated inside the hydrogel, shear stress imposed on them were found to be less than tolerable thresholds. The predicted cumulative albumin concentration over the 7 days of culture period showed a good agreement with the experimental data. Based on the critical role of oxygen supply to the hepatocytes, a parametric study was performed and the effect of various parameters was investigated. Results illustrated that convection mechanism was the dominant transport mechanism in the main-stream section contrary to the intra spheroids parts where the diffusion was the prevailing transport mechanism. In the hydrogel parts, the rate of diffusion and convection mechanisms were almost identical. As expected, higher perfusion rate would provide high oxygen level for the cells and, smaller spheroids with a diameter of 100 μm were at the low risk of hypoxic conditions due to short diffusive oxygen penetration depth. Numerical results evidenced that spheroids with diameter size >200 μm at low porosities (ε = 0.2-0.3) were at risk of oxygen depletion, especially at locations near the core center. Therefore, these results could be beneficial in preventing hypoxic conditions during in vitro experiments. The presented numerical model provides a numerical platform which can help researchers to design and optimize complex bioreactors and obtain numerical indexes of the main metabolites in a very short time prior to any fabrications. Such numerical indexes can be helpful in certifying the outcomes of forensic investigations.
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Affiliation(s)
| | - Bahar Firoozabadi
- School of Mechanical Engineering, Sharif University of Technology, Tehran, Iran
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Mallet M, Weiss N, Thabut D, Rudler M. Why and when to measure ammonemia in cirrhosis? Clin Res Hepatol Gastroenterol 2018; 42:505-511. [PMID: 29551609 DOI: 10.1016/j.clinre.2018.01.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 01/29/2018] [Accepted: 01/31/2018] [Indexed: 02/06/2023]
Abstract
Hyperammonemia plays a key role in the pathophysiology of hepatic encephalopathy (HE) and most HE treatments are ammonia-lowering drugs. However, the usefulness of measuring ammonemia in routine practice remains controversial and not recommended systematically even when neurological symptoms are present. First, ammonemia measurement should be carefully performed in order to avoid a falsely elevated result. When performed, a normal ammonemia in a cirrhotic patient with neurological symptoms should lead to reconsider the diagnosis of HE. Indeed, literature data show that most cirrhotic patients with HE have an elevated ammonemia, which is however individually poorly correlated with the severity of symptoms. Nevertheless, elevated ammonemia seems to be a factor of bad prognosis in cirrhosis. A decrease in ammonemia after treatments is well proven but it is not determined whether it is associated with clinical efficacy. Repeated measurements could be useful in this context, especially in non-responders, to help differentiating other causes of encephalopathy, such as drug induced. In acute liver failure, the prognostic value of hyperammonemia is well described and could help an early recognition the most severe forms of this disease. We will also discuss how integrating ammonemia into the diagnostic work-up of liver failure and/or encephalopathy. Ammonemia is also essential to diagnose urea cycle disorders or drug toxicity that both need specific interventions.
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Affiliation(s)
- Maxime Mallet
- Unité de soins intensifs d'hépatologie, service d'hépato-gastro-entérologie, groupe hospitalier Pitié-Salpêtrière Charles-Foix, Assistance publique-Hôpitaux de Paris, Paris, & Sorbonne universités, UPMC Université Paris 06, 47, boulevard de l'Hôpital, 75013 Paris, France; Brain Liver Pitié-Salpêtrière (BLIPS) study group, 47, boulevard de l'Hôpital, 75013, Paris, France
| | - Nicolas Weiss
- Brain Liver Pitié-Salpêtrière (BLIPS) study group, 47, boulevard de l'Hôpital, 75013, Paris, France; Sorbonne universités, UPMC université Paris 06, France & unité de réanimation neurologique, département de neurologie, groupe hospitalier Pitié-Salpêtrière Charles-Foix, pôle des maladies du système nerveux et institut de neurosciences translationnelles, IHU-A-ICM, 75013 Paris, France
| | - Dominique Thabut
- Unité de soins intensifs d'hépatologie, service d'hépato-gastro-entérologie, groupe hospitalier Pitié-Salpêtrière Charles-Foix, Assistance publique-Hôpitaux de Paris, Paris, & Sorbonne universités, UPMC Université Paris 06, 47, boulevard de l'Hôpital, 75013 Paris, France; Brain Liver Pitié-Salpêtrière (BLIPS) study group, 47, boulevard de l'Hôpital, 75013, Paris, France
| | - Marika Rudler
- Unité de soins intensifs d'hépatologie, service d'hépato-gastro-entérologie, groupe hospitalier Pitié-Salpêtrière Charles-Foix, Assistance publique-Hôpitaux de Paris, Paris, & Sorbonne universités, UPMC Université Paris 06, 47, boulevard de l'Hôpital, 75013 Paris, France; Brain Liver Pitié-Salpêtrière (BLIPS) study group, 47, boulevard de l'Hôpital, 75013, Paris, France.
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Chongsrisawat V, Damrongphol P, Ittiwut C, Ittiwut R, Suphapeetiporn K, Shotelersuk V. The phenotypic and mutational spectrum of Thai female patients with ornithine transcarbamylase deficiency. Gene 2018; 679:377-381. [PMID: 30223008 DOI: 10.1016/j.gene.2018.09.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 08/26/2018] [Accepted: 09/13/2018] [Indexed: 10/28/2022]
Abstract
Ornithine transcarbamylase deficiency (OTCD) is an X-linked urea cycle disorder affecting both males and females. Hemizygous males commonly present with severe hyperammonemic encephalopathy during the neonatal period. Heterozygous females have great phenotypic variability. The majority of female patients can manifest later in life or have unrecognized symptoms, making the diagnosis of OTCD in females very challenging. Here we report on three unrelated Thai female cases with OTCD presenting with different manifestations including aggressive behavior, acute liver failure and severe encephalopathy. Whole exome sequencing successfully identified disease-causing mutations in all three cases including two novel ones: the c.209_210delAA (p.Lys70Argfs*17) and the c.850T>A (p.Tyr284Asn). This study affirms variable symptoms in female patients with OTCD and emphasizes the importance of early recognition and prompt management for favorable outcomes. In addition, identification of two novel causative variants expands the genotypic spectrum of OTC.
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Affiliation(s)
- Voranush Chongsrisawat
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Ponghatai Damrongphol
- Center of Excellence for Medical Genomics, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand; Excellence Center for Medical Genetics, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok 10330, Thailand
| | - Chupong Ittiwut
- Center of Excellence for Medical Genomics, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand; Excellence Center for Medical Genetics, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok 10330, Thailand
| | - Rungnapa Ittiwut
- Center of Excellence for Medical Genomics, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand; Excellence Center for Medical Genetics, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok 10330, Thailand
| | - Kanya Suphapeetiporn
- Center of Excellence for Medical Genomics, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand; Excellence Center for Medical Genetics, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok 10330, Thailand.
| | - Vorasuk Shotelersuk
- Center of Excellence for Medical Genomics, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand; Excellence Center for Medical Genetics, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok 10330, Thailand
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Vara R, Dhawan A, Deheragoda M, Grünewald S, Pierre G, Heaton ND, Vilca-Melendez H, Hadžić N. Liver transplantation for neonatal-onset citrullinemia. Pediatr Transplant 2018; 22:e13191. [PMID: 29726081 DOI: 10.1111/petr.13191] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/12/2018] [Indexed: 12/27/2022]
Abstract
Citrullinemia or ASS deficiency in its classical form presents in the neonatal period with poor feeding, hyperammonemia, encephalopathy, seizures, and if untreated can be fatal. Despite advances in medical therapy, neurocognitive outcomes remain suboptimal. LT has emerged as a potential management option. A retrospective single-center review identified 7 children with a median age of 1.1 years (range, 0.6-5.8) at referral. Five children presented clinically, and 2 were treated prospectively from birth due to positive family history. All patients received standard medical and dietary therapy prior to LT. The indications for LT were frequent metabolic decompensations in 4, elective in 2, and ALF in 1. The median age at LT was 2.4 years (range, 1.3-6.5). Five patients received 6 left lateral segment grafts, one a live unrelated donor left lateral segment as an APOLT graft, and one a cadaveric whole liver graft as APOLT. One child required retransplantation due to hepatic artery thrombosis. Graft and patient survival were 86% and 100%, respectively. Median follow-up is 3.1 years (range, 0.1-4.1), and the median age at follow-up is 5.5 years (range, 4.0-9.8). There have been no metabolic decompensations in 6 children, while 1 patient (with APOLT) developed asymptomatic hyperammonemia with no clinical or histological signs of liver injury, requiring additional medical therapy. Our medium-term experience following LT in citrullinemia is favorable, demonstrating a positive transformation of the clinical phenotype.
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Affiliation(s)
- Roshni Vara
- Department of Inherited Metabolic Disease, Evelina London Children's Hospital, London, UK.,Paediatric Liver, GI and Nutrition Centre, King's College Hospital, London, UK
| | - Anil Dhawan
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital, London, UK
| | - Maesha Deheragoda
- Liver Histopathology, Institute of Liver Studies, King's College Hospital, London, UK
| | - Stephanie Grünewald
- Department of Paediatric Inherited Metabolic Disease, Institute of Child Health, Great Ormond Street Hospital for Children, UCL, London, UK
| | - Germaine Pierre
- Department of Paediatric Inherited Metabolic Disease, Bristol Children's Hospital, Bristol, UK
| | - Nigel D Heaton
- Liver Transplantation, Institute of Liver Studies, King's College Hospital, London, UK
| | - Hector Vilca-Melendez
- Liver Transplantation, Institute of Liver Studies, King's College Hospital, London, UK
| | - Nedim Hadžić
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital, London, UK
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Abstract
Once based mainly in paediatrics, inborn errors of metabolism (IEM), or inherited metabolic disorders (IMD) represent a growing adult medicine specialty. Individually rare these conditions have currently, a collective estimated prevalence of >1:800. Diagnosis has improved through expanded newborn screening programs, identification of potentially affected family members and greater awareness of symptomatic presentations in adolescence and in adulthood. Better survival and reduced mortality from previously lethal and debilitating conditions means greater numbers transition to adulthood. Pregnancy, once contraindicated for many, may represent a challenging but successful outcome. Successful pregnancies are now reported in a wide range of IEM. Significant challenges remain, given the biological stresses of pregnancy, parturition and the puerperium. Known diagnoses allow preventive and pre-emptive management. Unrecognized metabolic disorders especially, remain a preventable cause of maternal and neonatal mortality and morbidity. Increased awareness of these conditions amongst all clinicians is essential to expedite diagnosis and manage appropriately. This review aims to describe normal adaptations to pregnancy and discuss how various types of IEM may be affected. Relevant translational research and clinical experience will be reviewed with practical management aspects cited. Based on current literature, the impact of maternal IEM on mother and/or foetus, as well as how foetal IEM may affect the mother, will be considered. Insights gained from these rare disorders to more common conditions will be explored. Gaps in the literature, unanswered questions and steps to enhance further knowledge and systematically capture experience, such as establishment of an IEM-pregnancy registry, will be summarized.
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Affiliation(s)
- Gisela Wilcox
- School of Medical Sciences, Faculty of Biology Medicine & Health, University of Manchester, Manchester, UK.
- The Mark Holland Metabolic Unit, Salford Royal Foundation NHS Trust, Salford, Greater Manchester, M6 8HD, UK.
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Ivanovski I, Ješić M, Ivanovski A, Garavelli L, Ivanovski P. Metabolically based liver damage pathophysiology in patients with urea cycle disorders - A new hypothesis. World J Gastroenterol 2017; 23:7930-7938. [PMID: 29209134 PMCID: PMC5703922 DOI: 10.3748/wjg.v23.i44.7930] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 05/15/2017] [Accepted: 06/19/2017] [Indexed: 02/06/2023] Open
Abstract
The underlying pathophysiology of liver dysfunction in urea cycle disorders (UCDs) is still largely elusive. There is some evidence that the accumulation of urea cycle (UC) intermediates are toxic for hepatocyte mitochondria. It is possible that liver injury is directly caused by the toxicity of ammonia. The rarity of UCDs, the lack of checking of iron level in these patients, superficial knowledge of UC and an underestimation of the metabolic role of fumaric acid, are the main reasons that are responsible for the incomprehension of the mechanism of liver injury in patients suffering from UCDs. Owing to our routine clinical practice to screen for iron overload in severely ill neonates, with the focus on the newborns suffering from acute liver failure, we report a case of citrullinemia with neonatal liver failure and high blood parameters of iron overload. We hypothesize that the key is in the decreased-deficient fumaric acid production in the course of UC in UCDs that causes several sequentially intertwined metabolic disturbances with final result of liver iron overload. The presented hypothesis could be easily tested by examining the patients suffering from UCDs, for liver iron overload. This could be easily performed in countries with a high population and comprehensive national register for inborn errors of metabolism. Conclusion: Providing the hypothesis is correct, neonatal liver damage in patients having UCD can be prevented by the supplementation of pregnant women with fumaric or succinic acid, prepared in the form of iron supplementation pills. After birth, liver damage in patients having UCDs can be prevented by supplementation of these patients with zinc fumarate or zinc succinylate, as well.
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Affiliation(s)
- Ivan Ivanovski
- Clinical Genetics Unit, Department of Obstetrics and Pediatrics, AUSL-IRCCS of Reggio Emilia, 42123 Reggio Emilia, Italy
- Department of Surgical, Medical, Dental and Morphological Sciences with interest in Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Miloš Ješić
- School of Medicine University of Belgrade, Belgrade 11000, Serbia
- University Children’s Hospital, Belgrade 11000, Serbia
| | - Ana Ivanovski
- Faculty of Chemistry University of Belgrade, Belgrade 11000, Serbia
| | - Livia Garavelli
- Clinical Genetics Unit, Department of Obstetrics and Pediatrics, AUSL-IRCCS of Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Petar Ivanovski
- School of Medicine University of Belgrade, Belgrade 11000, Serbia
- University Children’s Hospital, Belgrade 11000, Serbia
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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: 43] [Impact Index Per Article: 6.1] [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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Weiss N, Mochel F, Rudler M, Demeret S, Lebray P, Conti F, Galanaud D, Ottolenghi C, Bonnefont JP, Dommergues M, Bernuau J, Thabut D. Peak hyperammonemia and atypical acute liver failure: The eruption of an urea cycle disorder during hyperemesis gravidarum. J Hepatol 2017; 68:S0168-8278(17)32289-4. [PMID: 28939132 DOI: 10.1016/j.jhep.2017.09.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 08/04/2017] [Accepted: 09/13/2017] [Indexed: 02/08/2023]
Abstract
Inborn urea cycle disorders are under-recognised metabolic causes of hyperammonemia in adults. A 28-year-old primigravida, seven weeks pregnant, affected by hyperemesis gravidarum developed acute liver injury (ALI) and then acute liver failure (ALF) in less than 48 h. Because the patient developed atypical features, especially mildly elevated aminotransferases contrasting with very high blood ammonia levels (281 μmol/L), concomitant with normal serum creatinine, an inborn error of metabolism was suspected. We performed emergency metabolic analyses, stopped all protein intake and started with intravenous (i.v.) high caloric intake, nitrogen scavenger drugs and haemodialysis. The neurological and hepatic status of the patient quickly improved together with normalisation of her ammonemia levels. High plasma glutamine and urinary orotic acid, alongside low plasma arginine, citrulline and ornithine were suggestive of an ornithine transcarbamylase deficiency, later confirmed by molecular analyses. Foetal sex was female, as determined by foetal DNA analysis in maternal blood, and foetal development was unremarkable throughout the pregnancy. Delivery was induced at 39 weeks with a close monitoring of ammonemia levels and i.v. perfusion of carbohydrates and lipids during labour and immediately post-partum to avoid hypercatabolism. Delivery was uneventful and the patient delivered a healthy female baby. Urea cycle disorders should be contemplated in non-jaundiced patients with ALI or ALF, severe hyperammonemia and normal serum creatinine regardless of serum aminotransferase levels. The prompt recognition of this rare condition and the rapid initiation of adequate metabolic therapy are mandatory to prevent irreversible neurological sequelae and to avoid liver transplantation.
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Affiliation(s)
- Nicolas Weiss
- Brain Liver Pitié-Salpêtrière (BLIPS) study group, Groupement Hospitalier Pitié-Salpêtrière-Charles Foix, Assistance Publique - Hôpitaux de Paris, Paris, France; Université Pierre et Marie Curie Paris 6, Sorbonne Universités, INSERM UMR_S 938, CDR Saint-Antoine Maladies métaboliques, biliaires et fibro-inflammatoires du foie, & Institut de Cardiométabolisme et Nutrition, ICAN, Paris, France; Unité de réanimation neurologique, Département de neurologie, pôle des maladies du système nerveux, Groupement Hospitalier Pitié-Salpêtrière-Charles Foix, Assistance Publique - Hôpitaux de Paris, Paris, France; Institut de neurosciences translationnelles IHU-A-ICM, Paris, France
| | - Fanny Mochel
- Inserm U 1127, CNRS UMR 7225, Sorbonne Universités, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, F-75013 Paris, France; Département de Génétique, Groupement Hospitalier Pitié-Salpêtrière-Charles Foix, Assistance Publique - Hôpitaux de Paris, Paris, France; Groupe de Recherche Clinique Neurométabolique, Université Pierre et Marie Curie, Paris, France
| | - Marika Rudler
- Brain Liver Pitié-Salpêtrière (BLIPS) study group, Groupement Hospitalier Pitié-Salpêtrière-Charles Foix, Assistance Publique - Hôpitaux de Paris, Paris, France; Université Pierre et Marie Curie Paris 6, Sorbonne Universités, INSERM UMR_S 938, CDR Saint-Antoine Maladies métaboliques, biliaires et fibro-inflammatoires du foie, & Institut de Cardiométabolisme et Nutrition, ICAN, Paris, France; UF de Soins Intensifs d'Hépato-gastroentérologie, Groupement Hospitalier Pitié-Salpêtrière-Charles Foix, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Sophie Demeret
- Unité de réanimation neurologique, Département de neurologie, pôle des maladies du système nerveux, Groupement Hospitalier Pitié-Salpêtrière-Charles Foix, Assistance Publique - Hôpitaux de Paris, Paris, France; Institut de neurosciences translationnelles IHU-A-ICM, Paris, France
| | - Pascal Lebray
- UF de Soins Intensifs d'Hépato-gastroentérologie, Groupement Hospitalier Pitié-Salpêtrière-Charles Foix, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Filomena Conti
- UF de transplantation hépatique, service d'Hépato-gastroentérologie, Groupement Hospitalier Pitié-Salpêtrière-Charles Foix, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Damien Galanaud
- Service de neuroradiologie, Groupement Hospitalier Pitié-Salpêtrière-Charles Foix, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Chris Ottolenghi
- Service de Biochimie Métabolique, Hôpital Necker-Enfants Malades, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jean-Paul Bonnefont
- Laboratoire de Génétique Moléculaire, Hôpital Necker-Enfants Malades, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marc Dommergues
- Service de Gynécologie-obstétrique, Groupement Hospitalier Pitié-Salpêtrière-Charles Foix, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Jacques Bernuau
- Service d'Hépatologie, Hôpital Beaujon, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Dominique Thabut
- Brain Liver Pitié-Salpêtrière (BLIPS) study group, Groupement Hospitalier Pitié-Salpêtrière-Charles Foix, Assistance Publique - Hôpitaux de Paris, Paris, France; Université Pierre et Marie Curie Paris 6, Sorbonne Universités, INSERM UMR_S 938, CDR Saint-Antoine Maladies métaboliques, biliaires et fibro-inflammatoires du foie, & Institut de Cardiométabolisme et Nutrition, ICAN, Paris, France; UF de Soins Intensifs d'Hépato-gastroentérologie, Groupement Hospitalier Pitié-Salpêtrière-Charles Foix, Assistance Publique - Hôpitaux de Paris, Paris, France.
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Rajabi F, Rodan LH, Jonas MM, Soul JS, Ullrich NJ, Wessel A, Waisbren SE, Tan WH, Berry GT. Liver Failure as the Presentation of Ornithine Transcarbamylase Deficiency in a 13-Month-Old Female. JIMD Rep 2017; 40:17-22. [PMID: 28887792 DOI: 10.1007/8904_2017_55] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 08/16/2017] [Accepted: 08/18/2017] [Indexed: 01/31/2023] Open
Abstract
Ornithine transcarbamylase deficiency (OTCD) is an X-linked urea cycle disorder with variable expressivity in heterozygous females. While liver function testing is often abnormal in patients with OTCD, liver failure is uncommon on presentation. A 13-month-old female with no significant past medical history presented with irritability, right arm weakness, and decreased appetite. Initial workup revealed hepatic dysfunction with an INR of 3.4, ammonia level of 75 μmol/L, and abnormal brain MRI with gyral edema with restricted diffusion, and patchy signal abnormality in basal ganglia. The MRI findings led to a putative diagnosis of acute disseminated encephalomyelitis prompting corticosteroid treatment. As steroid treatment was begun, she developed significant hepatocellular dysfunction with ALT 2,222 U/L, AST 630 U/L, prolonged INR, and elevated ammonia (213 μmol/L). Neurologic signs resolved and her ammonia level decreased (43 μmol/L) without further intervention; however, she had ongoing acute liver failure with coagulopathy and episodic irritability, managed as seronegative autoimmune hepatitis with partial response to corticosteroid therapy. At 18 months of age she presented with severe irritability with markedly increased ammonia (417 μmol/L). Plasma amino acids obtained several days prior to this acute episode demonstrated elevation in glutamine (2,725 μmol/L) and alanine (1,459 μmol/L). Biochemical testing demonstrated elevation of urine orotic acid (>240.6 mmol/mol creatinine). Genetic testing confirmed a heterozygous nonsense mutation in the OTC gene (c.958C>T, R320X). After treatment with ammonia scavengers and a protein-restricted diet, hepatic function normalized and irritability resolved. The diagnosis of a urea cycle disorder should be considered in patients with unexplained hepatic dysfunction.
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Affiliation(s)
- Farrah Rajabi
- Division of Genetics and Genomics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Lance H Rodan
- Division of Genetics and Genomics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Maureen M Jonas
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA, 02115, USA
| | - Janet S Soul
- Department of Neurology, Boston Children's Hospital, Boston, MA, 02115, USA
| | - Nicole J Ullrich
- Department of Neurology, Boston Children's Hospital, Boston, MA, 02115, USA
| | - Ann Wessel
- Division of Genetics and Genomics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Susan E Waisbren
- Division of Genetics and Genomics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Wen-Hann Tan
- Division of Genetics and Genomics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Gerard T Berry
- Division of Genetics and Genomics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA.
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Krijt J, Sokolová J, Ješina P, Dvořáková L, Řeboun M, Brennerová K, Mistrík M, Zeman J, Honzík T, Kožich V. Activity of the liver enzyme ornithine carbamoyltransferase (OTC) in blood: LC-MS/MS assay for non-invasive diagnosis of ornithine carbamoyltransferase deficiency. ACTA ACUST UNITED AC 2017; 55:1168-1177. [DOI: 10.1515/cclm-2016-0715] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 11/30/2016] [Indexed: 02/07/2023]
Abstract
Abstract
Background:
Liver enzymes are released from hepatocytes into circulation and their activity can be measured in the blood. We examined whether the plasma activity of the liver enzyme ornithine carbamoyltransferase, determined by a novel liquid chromatography-mass spectrometry (LC-MS/MS) assay, could be utilized for the detection of OTC deficiency (OTCD), an X-linked inborn error of the urea cycle.
Methods:
The plasma ornithine carbamoyltransferase (OTC) activity was assayed in the reverse reaction using isotopically labeled citrulline-d4 as a substrate and by determination of the product, ornithine-d4, by LC-MS/MS analysis.
Results:
The plasma OTC activity in the controls was in the range of 111–658 pkat/L (n=49, median 272 pkat/L), and the activity increased linearly with serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) activities in patients with hepatopathy. The OTC activity was subsequently determined in 32 individuals carrying mutations in the OTC gene, and OTC/ALT and OTC/AST ratios were calculated to account for the degree of hepatopathy, which is a common finding in OTCD. The OTC/ALT ratio enabled clear differentiation of OTCD hemizygotes (n=11, range 0–69×10−6) from controls (504–3440×10−6). This ratio also enabled the detection of 11 of 12 symptomatic heterozygotes (range 38–794×10−6), while this marker did not allow for reliable differentiation of asymptomatic heterozygotes (n=9) from controls.
Conclusions:
LC-MS/MS assay of plasma OTC activity enabled the detection of all hemizygous and the majority of symptomatic heterozygous OTCD patients in the tested cohort. This study demonstrates that non-invasive assay of enzymes expressed predominantly in the liver could be used as an alternative approach for diagnosing inborn errors of metabolism.
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Wang L, Bell P, Morizono H, He Z, Pumbo E, Yu H, White J, Batshaw ML, Wilson JM. AAV gene therapy corrects OTC deficiency and prevents liver fibrosis in aged OTC-knock out heterozygous mice. Mol Genet Metab 2017; 120:299-305. [PMID: 28283349 PMCID: PMC5423267 DOI: 10.1016/j.ymgme.2017.02.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 02/28/2017] [Accepted: 02/28/2017] [Indexed: 12/23/2022]
Abstract
Ornithine transcarbamylase (OTC) deficiency is an X-linked disorder of the urea cycle. Hemizygous males and heterozygous females may experience life-threatening elevations of ammonia in blood and brain, leading to irreversible cognitive impairment, coma, and death. Recent evidence of acute liver failure and fibrosis/cirrhosis is also emerging in OTC-deficient patients. Here, we investigated the long-term consequences of abnormal ureagenesis in female mice heterozygous (Het) for a null mutation in the OTC gene. Two-month-old Het OTC knockout (KO) mice received a single dose of self-complementary adeno-associated virus (AAV) encoding a codon-optimized human OTC gene at 1×1010, 3×1010, or 1×1011 vector genome copies per mouse. We compared liver pathology from 18-month-old treated Het OTC-KO mice, age-matched untreated Het OTC-KO mice, and WT littermates, and assessed urinary orotic acid levels and vector genome copies in liver at 4, 10, and 16months following vector administration. Het OTC-KO female mice showed evidence of liver inflammation and the eventual development of significant fibrosis. Treatment with AAV gene therapy not only corrected the underlying metabolic abnormalities, but also prevented the development of liver fibrosis. Our study demonstrates that early treatment of OTC deficiency with gene therapy may prevent clinically relevant consequences of chronic liver damage from developing.
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Affiliation(s)
- Lili Wang
- Gene Therapy Program, Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, 125 S. 31st Street, Philadelphia, PA 19104, USA
| | - Peter Bell
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 125 S. 31st Street, Philadelphia, PA 19104, USA
| | - Hiroki Morizono
- Center for Genetic Medicine Research, Children's Research Institute, Children's National Health System, 111 Michigan Ave., Washington, DC 20010, USA
| | - Zhenning He
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 125 S. 31st Street, Philadelphia, PA 19104, USA
| | - Elena Pumbo
- Center for Genetic Medicine Research, Children's Research Institute, Children's National Health System, 111 Michigan Ave., Washington, DC 20010, USA
| | - Hongwei Yu
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 125 S. 31st Street, Philadelphia, PA 19104, USA
| | - John White
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 125 S. 31st Street, Philadelphia, PA 19104, USA
| | - Mark L Batshaw
- Center for Genetic Medicine Research, Children's Research Institute, Children's National Health System, 111 Michigan Ave., Washington, DC 20010, USA
| | - James M Wilson
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 125 S. 31st Street, Philadelphia, PA 19104, USA.
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