Development of a Whole Blood Paper-Based Device for Phenylalanine Detection in the Context of PKU Therapy Monitoring

Emerging biosensors in Phenylketonuria

Phenylketonuria (PKU) is an autosomal recessive metabolic disorder resulting from deficient phenylalanine hydroxylase (PAH) enzyme activity, leading to impaired phenylalanine (Phe) metabolism. This condition can lead to intellectual disability, epilepsy, and behavioural issues. Treatment typically involves strict dietary restrictions on natural protein intake, supplemented with chemically manufactured protein substitutes containing amino acids other than Phe. Various approaches, including casein glycomacropeptide (GMP), tetrahydrobiopterin (BH4), phenylalanine ammonia-lyase (PAL) therapy, large neutral amino acid (LNAA) supplementation, enzyme therapy, gene therapy, and medical therapies, aim to prevent Phe transport in the brain to potentially treat PKU. Although newborn screening programs and early dietary interventions have enhanced outcomes of the potential treatment strategies, limitations still persist in this direction. These involve potent accuracy concerns in diagnosis due to the existence of antibiotics in blood of PKU patients, affecting growth of the bacteria in the bacterial inhibition assay. Monitoring involves complex methods for instance, mass spectrometry and high-pressure liquid chromatography, which involve shortcomings such as lengthy protocols and the need for specialized equipment. To address these limitations, adaptable testing formats like bio/nano sensors are emerging with their cost-effectiveness, biodegradability, and rapid, accurate, and sensitive detection capabilities, offering promising alternatives for PKU diagnosis. This review provides insights into current treatment and diagnostic approaches, emphasizing on the potential applications of the diverse sensors intended for PKU diagnosis.

Current Advances and Material Innovations in the Search for Novel Treatments of Phenylketonuria

Phenylketonuria (PKU) is a genetically inherited disease caused by a mutation of the gene encoding phenylalanine hydroxylase (PAH) and is the most common inborn error of amino acid metabolism. A deficiency of PAH leads to increased blood and brain levels of phenylalanine (Phe), which may cause permanent neurocognitive symptoms and developmental delays if untreated. Current management strategies for PKU consist of early detection through neonatal screening and implementation of a restrictive diet with minimal amounts of natural protein in combination with Phe-free supplements and low-protein foods to meet nutritional requirements. For milder forms of PKU, oral treatment with synthetic sapropterin (BH4), the cofactor of PAH, may improve metabolic control of Phe and allow for more natural protein to be included in the patient's diet. For more severe forms, daily injections of pegvaliase, a PEGylated variant of phenylalanine ammonia-lyase (PAL), may allow for normalization of blood Phe levels. However, the latter treatment has considerable drawbacks, notably a strong immunogenicity of the exogenous enzyme and the attached polymeric chains. Research for novel therapies of PKU makes use of innovative materials for drug delivery and state-of-the-art protein engineering techniques to develop treatments which are safer, more effective, and potentially permanent.

Engineering At-Home Dilution and Filtration Methods to Enable Paper-Based Colorimetric Biosensing in Human Blood with Cell-Free Protein Synthesis

Diagnostic blood tests can guide the administration of healthcare to save and improve lives. Most clinical biosensing blood tests require a trained technician and specialized equipment to process samples and interpret results, which greatly limits test accessibility. Colorimetric paper-based diagnostics have an equipment-free readout, but raw blood obscures a colorimetric response which has motivated diverse efforts to develop blood sample processing techniques. This work uses inexpensive readily-available materials to engineer user-friendly dilution and filtration methods for blood sample collection and processing to enable a proof-of-concept colorimetric biosensor that is responsive to glutamine in 50 µL blood drop samples in less than 30 min. Paper-based user-friendly blood sample collection and processing combined with CFPS biosensing technology represents important progress towards the development of at-home biosensors that could be broadly applicable to personalized healthcare.

A highly sensitive colorimetric approach based on tris (bipyridine) Ruthenium (II/III) mediator for the enzymatic detection of phenylalanine

The accurate monitoring of phenylalanine concentration plays a prominent role in the treatment of phenylketonuria (PKU). In this study, we present an enzymatic assay based on Phenylalanine Dehydrogenase/NAD⁺ and tris (bipyridine) Ruthenium (II/III) as a colorimetric mediator for the detection of Phenylalanine concentration. The amount of amino acid was quantitatively recognized by optical absorption measurements at 452 nm through the conversion of Ru (byp)₃ ³⁺ to Ru (byp)₃ ²⁺, which is induced by the neoformed NADH. A detection limit of 0.33 µM, a limit of quantification of 1.01 µM, and a sensitivity of 36.6 a.u nM^-1 were obtained. The proposed method was successfully tested using biological specimens from patients affected by hyperphenylalaninemia. The proposed enzymatic assay showed a high selectivity, making it a promising alternative for the development of versatile assays for the detection of phenylalanine in diluted serums.

Microfluidic Paper-Based Blood Plasma Separation Device as a Potential Tool for Timely Detection of Protein Biomarkers

A current challenge regarding microfluidic paper-based analytical devices (µPAD) for blood plasma separation (BPS) and electrochemical immunodetection of protein biomarkers is how to achieve a µPAD that yields enough plasma to retain the biomarker for affinity biosensing in a functionalized electrode system. This paper describes the development of a BPS µPAD to detect and quantify the S100B biomarker from peripheral whole blood. The device uses NaCl functionalized VF2 filter paper as a sample collection pad, an MF1 filter paper for plasma retention, and an optimized microfluidic channel geometry. An inverted light microscope, scanning electron microscope (SEM), and image processing software were used for visualizing BPS efficiency. A design of experiments (DOE) assessed the device’s efficacy using an S100B ELISA Kit to measure clinically relevant S100B concentrations in plasma. The BPS device obtained 50 μL of plasma from 300 μL of whole blood after 3.5 min. The statistical correlation of S100B concentrations obtained using plasma from standard centrifugation and the BPS device was 0.98. The BPS device provides a simple manufacturing protocol, short fabrication time, and is capable of S100B detection using ELISA, making one step towards the integration of technologies aimed at low-cost POC testing of clinically relevant biomarkers.

Smartphone-based colorimetric detection system for portable health tracking

Colorimetric tests for at-home health monitoring became popular 50 years ago with the advent of the urinalysis test strips, due to their reduced costs, practicality, and ease of operation. However, developing digital systems that can interface these sensors in an efficient manner remains a challenge. Efforts have been put towards the development of portable optical readout systems, such as smartphones. However, their use in daily settings is still limited by their error-prone nature associated to optical noise from the ambient lighting, and their low sensitivity. Here, a smartphone application (Colourine) to readout colorimetric signals was developed on Android OS and tested on commercial urinalysis test strips for pH, proteins, and glucose detection. The novelty of this approach includes two features: a pre-calibration step where the user is asked to take a photo of the commercial reference chart, and a CIE-RGB-to-HSV color space transformation of the acquired data. These two elements allow the background noise given by environmental lighting to be minimized. The sensors were characterized in the ambient light range 100-400 lx, yielding a reliable output. Readouts were taken from urine strips in buffer solutions of pH (5.0-9.0 units), proteins (0-500 mg dL^-1) and glucose (0-1000 mg dL^-1), yielding a limit of detection (LOD) of 0.13 units (pH), 7.5 mg dL^-1 (proteins) and 22 mg dL^-1 (glucose), resulting in an average LOD decrease by about 2.8 fold compared to the visual method.

Recent advances in lab-on-paper diagnostic devices using blood samples

Lab-on-paper, or microfluidic paper-based analytical devices (μPADs), use paper as a substrate material, and are patterned with a system of microchannels, reaction zones and sensing elements to perform analysis and detection. The sample transfer in such devices is performed by capillary action. As a result, external driving forces are not required, and hence the size and cost of the device are significantly reduced. Lab-on-paper devices have thus attracted significant attention for point-of-care medical diagnostic purposes in recent years, particularly in less-developed regions of the world lacking medical resources and infrastructures. This review discusses the major advances in lab-on-paper technology for blood analysis and diagnosis in the past five years. The review focuses particularly on the many clinical applications of lab-on-paper devices, including diabetes diagnosis, acute myocardial infarction (AMI) detection, kidney function diagnosis, liver function diagnosis, cholesterol and triglyceride (TG) analysis, sickle-cell disease (SCD) and phenylketonuria (PKU) analysis, virus analysis, C-reactive protein (CRP) analysis, blood ion analysis, cancer factor analysis, and drug analysis. The review commences by introducing the basic transmission principles, fabrication methods, structural characteristics, detection techniques, and sample pretreatment process of modern lab-on-paper devices. A comprehensive review of the most recent applications of lab-on-paper devices to the diagnosis of common human diseases using blood samples is then presented. The review concludes with a brief summary of the main challenges and opportunities facing the lab-on-paper technology field in the coming years.

Human Serum Phenylpyruvate Quantification Using Responsive 2D Photonic Crystal Hydrogels via Chemoselective Oxime Ligation: Progress toward Developing Phenylalanine-Sensing Elements

There is a need to develop at-home phenylalanine (Phe) test kits, analogous to home glucose meters, for phenylketonuria patients who must measure their blood Phe levels frequently to adjust their diet. Unfortunately, such test kits are not available yet because of the lack of simple and inexpensive Phe-sensing elements. With the goal of developing a Phe-sensing element, we fabricated two-dimensional photonic crystal (2DPC) hydrogels that quantify human serum phenylpyruvate (PhPY), which is the product of the reaction between Phe and the enzyme phenylalanine dehydrogenase. The PhPY-sensing hydrogels have oxyamine recognition groups that link PhPY to the hydrogel polymer network via chemoselective oxime ligation. This structural modification induces the hydrogel to swell, which then increases interparticle spacings within the embedded 2DPC. The PhPY-induced particle spacing changes are measured from light diffraction and used to quantify the PhPY concentrations. The estimated limit of detection of PhPY in human serum for a detection time of 30 min is 19 μM, which is comparable to the minimum blood Phe concentrations of healthy people. Besides the potential application for developing Phe-sensing elements, this new hydrogel sensing approach via chemoselective oxime ligation is generalizable to the development of other chemical sensors working in complex biological environments.

Recent Advances of Fluid Manipulation Technologies in Microfluidic Paper-Based Analytical Devices (μPADs) toward Multi-Step Assays

Microfluidic paper-based analytical devices (μPADs) have been suggested as alternatives for developing countries with suboptimal medical conditions because of their low diagnostic cost, high portability, and disposable characteristics. Recently, paper-based diagnostic devices enabling multi-step assays have been drawing attention, as they allow complicated tests, such as enzyme-linked immunosorbent assay (ELISA) and polymerase chain reaction (PCR), which were previously only conducted in the laboratory, to be performed on-site. In addition, user convenience and price of paper-based diagnostic devices are other competitive points over other point-of-care testing (POCT) devices, which are more critical in developing countries. Fluid manipulation technologies in paper play a key role in realizing multi-step assays via μPADs, and the expansion of biochemical applications will provide developing countries with more medical benefits. Therefore, we herein aimed to investigate recent fluid manipulation technologies utilized in paper-based devices and to introduce various approaches adopting several principles to control fluids on papers. Fluid manipulation technologies are classified into passive and active methods. While passive valves are structurally simple and easy to fabricate, they are difficult to control in terms of flow at a specific spatiotemporal condition. On the contrary, active valves are more complicated and mostly require external systems, but they provide much freedom of fluid manipulation and programmable operation. Both technologies have been revolutionized in the way to compensate for their limitations, and their advances will lead to improved performance of μPADs, increasing the level of healthcare around the world.

Characterization methods in porous materials for the rational design of multi-step processing in the context of a paper microfluidic phenylalanine test

A promising application of paper microfluidics is the translation of gold-standard multi-step laboratory tests to a disposable paper-based format for decentralized diagnostic or therapeutic testing. This often entails conversion of bench-top processing of macro-volume samples to the processing of micro-volume samples within a porous matrix, and requires detailed characterization of fluid and reagent interactions within the porous material(s) of the device. The current study focuses on rational device design through the characterization of fluid and reagent interactions in polysulfone and glass fiber substrates for multi-step sample processing. Specifically, we demonstrate how the characterization of fluidic compatibility between substrates, chemical compatibility between reagents and substrates, sample pH, and sample transport can be used to inform device design in the context of a two-reaction detection scheme for phenylalanine in porous materials. Finally, we demonstrate detection of phenylalanine from human whole blood, and discuss the multiple strengths of the current design over a previous version.

Phenylalanine Monitoring via Aptamer-Field-Effect Transistor Sensors

Determination of the amino acid phenylalanine is important for lifelong disease management in patients with phenylketonuria, a genetic disorder in which phenylalanine accumulates and persists at levels that alter brain development and cause permanent neurological damage and cognitive dysfunction. Recent approaches for treating phenylketonuria focus on injectable medications that efficiently break down phenylalanine but sometimes result in detrimentally low phenylalanine levels. We have identified new DNA aptamers for phenylalanine in two formats, initially as fluorescent sensors and then, incorporated with field-effect transistors (FETs). Aptamer-FET sensors detected phenylalanine over a wide range of concentrations (fM to mM). para-Chlorophenylalanine, which inhibits the enzyme that converts phenylalanine to tyrosine, was used to induce hyperphenylalaninemia during brain development in mice. Aptamer-FET sensors were specific for phenylalanine versus para-chlorophenylalanine and differentiated changes in mouse serum phenylalanine at levels expected in patients. Aptamer-FETs can be used to investigate models of hyperphenylalanemia in the presence of structurally related enzyme inhibitors, as well as naturally occurring amino acids. Nucleic acid-based receptors that discriminate phenylalanine analogs, some that differ by a single substituent, indicate a refined ability to identify aptamers with binding pockets tailored for high affinity and specificity. Aptamers of this type integrated into FETs enable rapid, electronic, label-free phenylalanine sensing.

Paper-based microfluidic devices based on 3D network polymer hydrogel for the determination of glucose in human whole blood

In this study, optical microfluidic paper analytical devices (μPADs) for glucose detection from whole blood samples with a small sample volume (2 μL) have been developed on a single paper. In the proposed method, a mushroom-shaped analytical device contains a sample inlet zone and a detection zone. When blood is dripped onto the inlet region of a μPAD, the plasma diffuses to the detection region. The detection region is implanted with a metallic three-dimensional (3D) polymer hydrogel vehicle. The gel vehicle consists of a copper complex that responds to oxygen changes and glucose oxidase (GOx) immobilized inside the gel as a bioactivity preservative. The phosphorescence of the copper complex is enhanced by oxygen consumed by detection of glucose with a limit of detection (S/N = 3) of 0.44 mM, and the total analysis of the sample is completed within 1 min. The validity of the proposed research is demonstrated using control samples and real-world whole blood samples of glucose concentrations ranging from 3 to 200 mM, and the detection results are shown to be in agreement with those obtained using a glucometer. Attaining a simple device for analysing glucose in human whole blood without any pretreatment procedures and having a broad sensing range while consuming a small sample volume remain challenging; thus, our new analytical device is of great interest.

A smartphone fluorescence imaging-based mobile biosensing system integrated with a passive fluidic control cartridge for minimal user intervention and high accuracy

A key challenge for realizing mobile device-based on-the-spot environmental biodetection is that a biosensor integrated with a fluid handling sensor cartridge must have acceptable accuracy comparable to that of conventional standard analytical methods. Furthermore, the user interface must be easy to operate, technologically plausible, and concise. Herein, we introduced an advanced smartphone imaging-based fluorescence microscope designed for Hg2+ monitoring by utilizing a biosensor cartridge that reduced user intervention via time-sequenced passive fluid handling. The cartridge also employed a metal-nanostructured plastic substrate for complementing the fluorescence signal output; this helped the realization of high-accuracy detection, in which a ratiometric dual-wavelength detection method was applied. Using 30 samples of Hg2+-spiked wastewater, we showed that our device, which has a detection limit of ∼1 pM, can perform analytical assays accurately. The detection results from our method were in good linearity and agreement with those of conventional standard methods. We conclude that the integration of a simple-to-use biosensor cartridge, fluorescence signal-enhancing substrate, dual-wavelength detection, and quantitative image data processing on a smartphone has great potential to make any population accessible to small-molecule detection, which has been performed in centralized laboratories for environmental monitoring.

Flow controllable three-dimensional paper-based microfluidic analytical devices fabricated by 3D printing technology

In most cases, three-dimensional paper-based microfluidic analytical devices (3D-μPADs) were fabricated manually by stacking or folding methods. For the first time, digital light processing stereolithography (DLP-SLA) 3D printing technology was adopted to automatically make 3D-μPADs. In the fabrication process, a printing pause was set between two layers to allow paper to be placed in the resin tank. The resin on the fresh paper spontaneously bonded to the former cured paper layer during curing, thus realizing the automatic bonding and alignment between different layers of paper and avoiding the human participation and errors as in stacking and folding methods. There was a gap between two vertical aligned flow paths, therefore the liquid did not flow spontaneously from the upper layer to the lower layer. Most of the fluid flow in 3D-μPADs was spontaneous or manually activated, which was not conducive to complex assays that require different regents to be delivered sequentially. Herein, we used an electric field or airflow to trigger the fluid flow and demonstrated the flow controllability by a proof-of-concept colorimetric assay. The limits of detection of glucose and albumin were 0.8 mM and 3.5 μM, respectively, which were sufficient for clinical requirements. Given the characteristic of flow controllability, we believe that the proposed 3D-μPADs have great potential to make paper-based complex assays automated and programmable.

From Point-of-Care Testing to eHealth Diagnostic Devices (eDiagnostics)

Point-of-care devices were originally designed to allow medical testing at or near the point of care by health-care professionals. Some point-of-care devices allow medical self-testing at home but cannot fully cover the growing diagnostic needs of eHealth systems that are under development in many countries. A number of easy-to-use, network-connected diagnostic devices for self-testing are needed to allow remote monitoring of patients' health. This Outlook highlights the essential characteristics of diagnostic devices for eHealth settings and indicates point-of-care technologies that may lead to the development of new devices. It also describes the most representative examples of simple-to-use, point-of-care devices that have been used for analysis of untreated biological samples.

Semisynthetic sensor proteins enable metabolic assays at the point of care

Monitoring metabolites at the point of care could improve the diagnosis and management of numerous diseases. Yet for most metabolites, such assays are not available. We introduce semisynthetic, light-emitting sensor proteins for use in paper-based metabolic assays. The metabolite is oxidized by nicotinamide adenine dinucleotide phosphate, and the sensor changes color in the presence of the reduced cofactor, enabling metabolite quantification with the use of a digital camera. The approach makes any metabolite that can be oxidized by the cofactor a candidate for quantitative point-of-care assays, as shown for phenylalanine, glucose, and glutamate. Phenylalanine blood levels of phenylketonuria patients were analyzed at the point of care within minutes with only 0.5 microliters of blood. Results were within 15% of those obtained with standard testing methods.

Turning the Page: Advancing Paper-Based Microfluidics for Broad Diagnostic Application

Infectious diseases are a major global health issue. Diagnosis is a critical first step in effectively managing their spread. Paper-based microfluidic diagnostics first emerged in 2007 as a low-cost alternative to conventional laboratory testing, with the goal of improving accessibility to medical diagnostics in developing countries. In this review, we examine the advances in paper-based microfluidic diagnostics for medical diagnosis in the context of global health from 2007 to 2016. The theory of fluid transport in paper is first presented. The next section examines the strategies that have been employed to control fluid and analyte transport in paper-based assays. Tasks such as mixing, timing, and sequential fluid delivery have been achieved in paper and have enabled analytical capabilities comparable to those of conventional laboratory methods. The following section examines paper-based sample processing and analysis. The most impactful advancement here has been the translation of nucleic acid analysis to a paper-based format. Smartphone-based analysis is another exciting development with potential for wide dissemination. The last core section of the review highlights emerging health applications, such as male fertility testing and wearable diagnostics. We conclude the review with the future outlook, remaining challenges, and emerging opportunities.

Beyond Wicking: Expanding the Role of Patterned Paper as the Foundation for an Analytical Platform

While a number of assays for soluble analytes have been developed using paper-based microfluidic devices, the detection and analysis of blood cells has remained an outstanding challenge. In this Feature, we discuss how the properties of paper determine the performance of paper-based microfluidic devices and permit the design of cellular assays, which can ultimately impact disparities in healthcare that exist in limited-resource settings.

Toward practical application of paper-based microfluidics for medical diagnostics: state-of-the-art and challenges

Microfluidic paper-based analytical devices (μPADs) have emerged as a promising diagnostic platform a decade ago. In contrast to highly active academic developments, their entry into real-life applications is still very limited. This discrepancy is attributed to the gap between research developments and their practical utility, particularly in the aspects of operational simplicity, long-term stability of devices, and associated equipment. On the basis of these backgrounds, this review attempts to: 1) identify the reasons for success of paper-based devices already in the market, 2) describe the current status and remaining issues of μPADs in terms of operational complexity, signal interpretation approaches, and storage stability, and 3) discuss the possibility of mass production based on established manufacturing technologies. Finally, the state-of-the-art in commercialisation of μPADs is discussed, and the "upgrades" required from a laboratory-based prototype to an end user device are demonstrated on a specific example.

Progress in the development and integration of fluid flow control tools in paper microfluidics

Paper microfluidics is a rapidly growing subfield of microfluidics in which paper-like porous materials are used to create analytical devices. There is a need for higher performance field-use tests for many application domains including human disease diagnosis, environmental monitoring, and veterinary medicine. A key factor in creating high performance paper-based devices is the ability to manipulate fluid flow within the devices. This critical review is focused on the progress that has been made in (i) the development of fluid flow control tools and (ii) the integration of those tools into paper microfluidic devices. Further, we strive to be comprehensive in our presentation and provide historical context through discussion and performance comparisons, when possible, of both relevant earlier work and recent work. Finally, we discuss the major areas of focus for fluid flow methods development to advance the potential of paper microfluidics for high-performance field applications.

A facile method for urinary phenylalanine measurement on paper-based lab-on-chip for PKU therapy monitoring

A miniaturized paper-based lab-on-chip (LoC) was developed for the facile measurement of urinary Phe (phenylalanine) level on PKU (Phenylketonuria) treated patient.