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Shchelochkov OA, Farmer CA, Chlebowski C, Adedipe D, Ferry S, Manoli I, Pass A, McCoy S, Van Ryzin C, Sloan J, Thurm A, Venditti CP. Intellectual disability and autism in propionic acidemia: a biomarker-behavioral investigation implicating dysregulated mitochondrial biology. Mol Psychiatry 2024; 29:974-981. [PMID: 38200289 PMCID: PMC11176071 DOI: 10.1038/s41380-023-02385-5] [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: 12/05/2022] [Revised: 03/13/2023] [Accepted: 12/14/2023] [Indexed: 01/12/2024]
Abstract
Propionic acidemia (PA) is an autosomal recessive condition (OMIM #606054), wherein pathogenic variants in PCCA and PCCB impair the activity of propionyl-CoA carboxylase. PA is associated with neurodevelopmental disorders, including intellectual disability (ID) and autism spectrum disorder (ASD); however, the correlates and mechanisms of these outcomes remain unknown. Using data from a subset of participants with PA enrolled in a dedicated natural history study (n = 33), we explored associations between neurodevelopmental phenotypes and laboratory parameters. Twenty (61%) participants received an ID diagnosis, and 12 of the 31 (39%) who were fully evaluated received the diagnosis of ASD. A diagnosis of ID, lower full-scale IQ (sample mean = 65 ± 26), and lower adaptive behavior composite scores (sample mean = 67 ± 23) were associated with several biomarkers. Higher concentrations of plasma propionylcarnitine, plasma total 2-methylcitrate, serum erythropoietin, and mitochondrial biomarkers plasma FGF21 and GDF15 were associated with a more severe ID profile. Reduced 1-13C-propionate oxidative capacity and decreased levels of plasma and urinary glutamine were also associated with a more severe ID profile. Only two parameters, increased serum erythropoietin and decreased plasma glutamine, were associated with ASD. Plasma glycine, one of the defining features of PA, was not meaningfully associated with either ID or ASD. Thus, while both ID and ASD were commonly observed in our PA cohort, only ID was robustly associated with metabolic parameters. Our results suggest that disease severity and associated mitochondrial dysfunction may play a role in CNS complications of PA and identify potential biomarkers and candidate surrogate endpoints.
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Affiliation(s)
- Oleg A Shchelochkov
- Organic Acid Research Section, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Cristan A Farmer
- Neurodevelopmental and Behavioral Phenotyping Service, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Colby Chlebowski
- Neurodevelopmental and Behavioral Phenotyping Service, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Dee Adedipe
- Neurodevelopmental and Behavioral Phenotyping Service, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Susan Ferry
- Organic Acid Research Section, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Irini Manoli
- Organic Acid Research Section, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Alexandra Pass
- Organic Acid Research Section, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Samantha McCoy
- Organic Acid Research Section, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Carol Van Ryzin
- Organic Acid Research Section, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Jennifer Sloan
- Organic Acid Research Section, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Audrey Thurm
- Neurodevelopmental and Behavioral Phenotyping Service, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Charles P Venditti
- Organic Acid Research Section, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, 20892, USA.
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2
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Manoli I, Sysol JR, Head PE, Epping MW, Gavrilova O, Crocker MK, Sloan JL, Koutsoukos SA, Wang C, Ktena YP, Mendelson S, Pass AR, Zerfas PM, Hoffmann V, Vernon HJ, Fletcher LA, Reynolds JC, Tsokos MG, Stratakis CA, Voss SD, Chen KY, Brown RJ, Hamosh A, Berry GT, Chen XS, Yanovski JA, Venditti CP. Lipodystrophy in methylmalonic acidemia associated with elevated FGF21 and abnormal methylmalonylation. JCI Insight 2024; 9:e174097. [PMID: 38271099 DOI: 10.1172/jci.insight.174097] [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: 07/24/2023] [Accepted: 01/09/2024] [Indexed: 01/27/2024] Open
Abstract
A distinct adipose tissue distribution pattern was observed in patients with methylmalonyl-CoA mutase deficiency, an inborn error of branched-chain amino acid (BCAA) metabolism, characterized by centripetal obesity with proximal upper and lower extremity fat deposition and paucity of visceral fat, that resembles familial multiple lipomatosis syndrome. To explore brown and white fat physiology in methylmalonic acidemia (MMA), body composition, adipokines, and inflammatory markers were assessed in 46 patients with MMA and 99 matched controls. Fibroblast growth factor 21 levels were associated with acyl-CoA accretion, aberrant methylmalonylation in adipose tissue, and an attenuated inflammatory cytokine profile. In parallel, brown and white fat were examined in a liver-specific transgenic MMA mouse model (Mmut-/- TgINS-Alb-Mmut). The MMA mice exhibited abnormal nonshivering thermogenesis with whitened brown fat and had an ineffective transcriptional response to cold stress. Treatment of the MMA mice with bezafibrates led to clinical improvement with beiging of subcutaneous fat depots, which resembled the distribution seen in the patients. These studies defined what we believe to be a novel lipodystrophy phenotype in patients with defects in the terminal steps of BCAA oxidation and demonstrated that beiging of subcutaneous adipose tissue in MMA could readily be induced with small molecules.
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Affiliation(s)
- Irini Manoli
- Metabolic Medicine Branch, National Human Genome Research Institute
| | - Justin R Sysol
- Metabolic Medicine Branch, National Human Genome Research Institute
| | | | | | - Oksana Gavrilova
- Mouse Metabolism Core, National Institute of Diabetes and Digestive and Kidney Diseases
| | - Melissa K Crocker
- Section on Growth and Obesity, Eunice Kennedy Shriver National Institute of Child Health and Human Development; and
| | - Jennifer L Sloan
- Metabolic Medicine Branch, National Human Genome Research Institute
| | | | - Cindy Wang
- Metabolic Medicine Branch, National Human Genome Research Institute
| | - Yiouli P Ktena
- Metabolic Medicine Branch, National Human Genome Research Institute
| | - Sophia Mendelson
- Section on Growth and Obesity, Eunice Kennedy Shriver National Institute of Child Health and Human Development; and
| | - Alexandra R Pass
- Metabolic Medicine Branch, National Human Genome Research Institute
| | - Patricia M Zerfas
- Office of Research Services, Division of Veterinary Resources, NIH, Bethesda, Maryland, USA
| | - Victoria Hoffmann
- Office of Research Services, Division of Veterinary Resources, NIH, Bethesda, Maryland, USA
| | - Hilary J Vernon
- Department of Genetic Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Laura A Fletcher
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases
| | | | - Maria G Tsokos
- Ultrastructural Pathology Section, Center for Cancer Research; and
| | - Constantine A Stratakis
- Section on Endocrinology & Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, USA
| | - Stephan D Voss
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kong Y Chen
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases
| | - Rebecca J Brown
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases
| | - Ada Hamosh
- Department of Genetic Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Gerard T Berry
- Division of Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Xiaoyuan Shawn Chen
- Laboratory of Molecular Imaging and Nanomedicine, National Institute of Biomedical Imaging and Bioengineering, NIH, Bethesda, Maryland, USA
| | - Jack A Yanovski
- Section on Growth and Obesity, Eunice Kennedy Shriver National Institute of Child Health and Human Development; and
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Lucienne M, Gerlini R, Rathkolb B, Calzada-Wack J, Forny P, Wueest S, Kaech A, Traversi F, Forny M, Bürer C, Aguilar-Pimentel A, Irmler M, Beckers J, Sauer S, Kölker S, Dewulf JP, Bommer GT, Hoces D, Gailus-Durner V, Fuchs H, Rozman J, Froese DS, Baumgartner MR, de Angelis MH. Insights into energy balance dysregulation from a mouse model of methylmalonic aciduria. Hum Mol Genet 2023; 32:2717-2734. [PMID: 37369025 PMCID: PMC10460489 DOI: 10.1093/hmg/ddad100] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/25/2023] [Accepted: 06/19/2023] [Indexed: 06/29/2023] Open
Abstract
Inherited disorders of mitochondrial metabolism, including isolated methylmalonic aciduria, present unique challenges to energetic homeostasis by disrupting energy-producing pathways. To better understand global responses to energy shortage, we investigated a hemizygous mouse model of methylmalonyl-CoA mutase (Mmut)-type methylmalonic aciduria. We found Mmut mutant mice to have reduced appetite, energy expenditure and body mass compared with littermate controls, along with a relative reduction in lean mass but increase in fat mass. Brown adipose tissue showed a process of whitening, in line with lower body surface temperature and lesser ability to cope with cold challenge. Mutant mice had dysregulated plasma glucose, delayed glucose clearance and a lesser ability to regulate energy sources when switching from the fed to fasted state, while liver investigations indicated metabolite accumulation and altered expression of peroxisome proliferator-activated receptor and Fgf21-controlled pathways. Together, these shed light on the mechanisms and adaptations behind energy imbalance in methylmalonic aciduria and provide insight into metabolic responses to chronic energy shortage, which may have important implications for disease understanding and patient management.
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Affiliation(s)
- Marie Lucienne
- Division of Metabolism and Children’s Research Center, University Children’s Hospital Zurich, University of Zurich, 8032 Zurich, Switzerland
- radiz – Rare Disease Initiative Zurich, Clinical Research Priority Program for Rare Diseases, University of Zurich, Zurich, Switzerland
- Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Raffaele Gerlini
- Institute of Experimental Genetics and German Mouse Clinic, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
| | - Birgit Rathkolb
- Institute of Experimental Genetics and German Mouse Clinic, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
- Institute of Molecular Animal Breeding and Biotechnology, Gene Center, Ludwig-Maximilians-University München, Munich, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Julia Calzada-Wack
- Institute of Experimental Genetics and German Mouse Clinic, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
| | - Patrick Forny
- Division of Metabolism and Children’s Research Center, University Children’s Hospital Zurich, University of Zurich, 8032 Zurich, Switzerland
| | - Stephan Wueest
- Division of Pediatric Endocrinology and Diabetology and Children’s Research Center, University Children's Hospital, University of Zurich, 8032 Zurich, Switzerland
| | - Andres Kaech
- Center for Microscopy and Image Analysis, University of Zurich, Zurich, Switzerland
| | - Florian Traversi
- Division of Metabolism and Children’s Research Center, University Children’s Hospital Zurich, University of Zurich, 8032 Zurich, Switzerland
| | - Merima Forny
- Division of Metabolism and Children’s Research Center, University Children’s Hospital Zurich, University of Zurich, 8032 Zurich, Switzerland
| | - Céline Bürer
- Division of Metabolism and Children’s Research Center, University Children’s Hospital Zurich, University of Zurich, 8032 Zurich, Switzerland
| | - Antonio Aguilar-Pimentel
- Institute of Experimental Genetics and German Mouse Clinic, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
| | - Martin Irmler
- Institute of Experimental Genetics and German Mouse Clinic, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
| | - Johannes Beckers
- Institute of Experimental Genetics and German Mouse Clinic, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Sven Sauer
- Division of Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital, Heidelberg, Germany
| | - Stefan Kölker
- Division of Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital, Heidelberg, Germany
| | - Joseph P Dewulf
- Department of Biochemistry, de Duve Institute, UCLouvain, Brussels, Belgium
- Walloon Excellence in Life Sciences and Biotechnology (WELBIO), Brussels, Belgium
- Department of Laboratory Medicine, Cliniques universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Guido T Bommer
- Department of Biochemistry, de Duve Institute, UCLouvain, Brussels, Belgium
- Walloon Excellence in Life Sciences and Biotechnology (WELBIO), Brussels, Belgium
| | - Daniel Hoces
- Institute of Food, Nutrition and Health, D-HEST, ETH Zurich, Zurich, Switzerland
| | - Valerie Gailus-Durner
- Institute of Experimental Genetics and German Mouse Clinic, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
| | - Helmut Fuchs
- Institute of Experimental Genetics and German Mouse Clinic, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
| | - Jan Rozman
- Institute of Experimental Genetics and German Mouse Clinic, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - D Sean Froese
- Division of Metabolism and Children’s Research Center, University Children’s Hospital Zurich, University of Zurich, 8032 Zurich, Switzerland
- radiz – Rare Disease Initiative Zurich, Clinical Research Priority Program for Rare Diseases, University of Zurich, Zurich, Switzerland
| | - Matthias R Baumgartner
- Division of Metabolism and Children’s Research Center, University Children’s Hospital Zurich, University of Zurich, 8032 Zurich, Switzerland
- radiz – Rare Disease Initiative Zurich, Clinical Research Priority Program for Rare Diseases, University of Zurich, Zurich, Switzerland
- Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Martin Hrabě de Angelis
- Institute of Experimental Genetics and German Mouse Clinic, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
- Chair of Experimental Genetics, School of Life Science Weihenstephan, Technische Universität München, Freising, Germany
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Manoli I, Gebremariam A, McCoy S, Pass AR, Gagné J, Hall C, Ferry S, Van Ryzin C, Sloan JL, Sacchetti E, Catesini G, Rizzo C, Martinelli D, Spada M, Dionisi-Vici C, Venditti CP. Biomarkers to predict disease progression and therapeutic response in isolated methylmalonic acidemia. J Inherit Metab Dis 2023; 46:554-572. [PMID: 37243446 PMCID: PMC10330948 DOI: 10.1002/jimd.12636] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/28/2023] [Accepted: 05/19/2023] [Indexed: 05/28/2023]
Abstract
Methylmalonic Acidemia (MMA) is a heterogenous group of inborn errors of metabolism caused by a defect in the methylmalonyl-CoA mutase (MMUT) enzyme or the synthesis and transport of its cofactor, 5'-deoxy-adenosylcobalamin. It is characterized by life-threatening episodes of ketoacidosis, chronic kidney disease, and other multiorgan complications. Liver transplantation can improve patient stability and survival and thus provides clinical and biochemical benchmarks for the development of hepatocyte-targeted genomic therapies. Data are presented from a US natural history protocol that evaluated subjects with different types of MMA including mut-type (N = 91), cblB-type (15), and cblA-type MMA (17), as well as from an Italian cohort of mut-type (N = 19) and cblB-type MMA (N = 2) subjects, including data before and after organ transplantation in both cohorts. Canonical metabolic markers, such as serum methylmalonic acid and propionylcarnitine, are variable and affected by dietary intake and renal function. We have therefore explored the use of the 1-13 C-propionate oxidation breath test (POBT) to measure metabolic capacity and the changes in circulating proteins to assess mitochondrial dysfunction (fibroblast growth factor 21 [FGF21] and growth differentiation factor 15 [GDF15]) and kidney injury (lipocalin-2 [LCN2]). Biomarker concentrations are higher in patients with the severe mut0 -type and cblB-type MMA, correlate with a decreased POBT, and show a significant response postliver transplant. Additional circulating and imaging markers to assess disease burden are necessary to monitor disease progression. A combination of biomarkers reflecting disease severity and multisystem involvement will be needed to help stratify patients for clinical trials and assess the efficacy of new therapies for MMA.
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Affiliation(s)
- Irini Manoli
- Metabolic Medicine Branch, National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, MD, USA
| | - Abigael Gebremariam
- Metabolic Medicine Branch, National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, MD, USA
| | - Samantha McCoy
- Metabolic Medicine Branch, National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, MD, USA
| | - Alexandra R. Pass
- Metabolic Medicine Branch, National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, MD, USA
| | - Jack Gagné
- Metabolic Medicine Branch, National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, MD, USA
| | - Camryn Hall
- Metabolic Medicine Branch, National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, MD, USA
| | - Susan Ferry
- Metabolic Medicine Branch, National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, MD, USA
| | - Carol Van Ryzin
- Metabolic Medicine Branch, National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, MD, USA
| | - Jennifer L. Sloan
- Metabolic Medicine Branch, National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, MD, USA
| | - Elisa Sacchetti
- Division of Metabolic Diseases, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Giulio Catesini
- Division of Metabolic Diseases, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Cristiano Rizzo
- Division of Metabolic Diseases, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Diego Martinelli
- Division of Metabolic Diseases, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Marco Spada
- Division of Hepatobiliopancreatic Surgery, Liver and Kidney Tranplantation, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
- European Research Network TransplantChild
| | - Carlo Dionisi-Vici
- Division of Metabolic Diseases, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Charles P. Venditti
- Metabolic Medicine Branch, National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, MD, USA
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Venturoni LE, Chandler RJ, Liao J, Hoffmann V, Ramesh N, Gordo S, Chau N, Venditti CP. Growth advantage of corrected hepatocytes in a juvenile model of methylmalonic acidemia following liver directed adeno-associated viral mediated nuclease-free genome editing. Mol Genet Metab 2022; 137:1-8. [PMID: 35868241 PMCID: PMC9872049 DOI: 10.1016/j.ymgme.2022.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/30/2022] [Accepted: 06/30/2022] [Indexed: 01/26/2023]
Abstract
Methylmalonic acidemia (MMA) is a rare and severe inherited metabolic disease typically caused by mutations of the methylmalonyl-CoA mutase (MMUT) gene. Despite medical management, patients with MMA experience frequent episodes of metabolic instability, severe morbidity, and early mortality. In several preclinical studies, systemic gene therapy has demonstrated impressive improvement in biochemical and clinical phenotypes of MMA murine models. One approach uses a promoterless adeno-associated viral (AAV) vector that relies upon homologous recombination to achieve site-specific in vivo gene addition of MMUT into the last coding exon of albumin (Alb), generating a fused Alb-MMUT transcript after successful editing. We have previously demonstrated that nuclease-free AAV mediated Alb editing could effectively treat MMA mice in the neonatal period and noted that hepatocytes had a growth advantage after correction. Here, we use a transgenic knock-out mouse model of MMA that recapitulates severe clinical and biochemical symptoms to assess the benefits of Alb editing in juvenile animals. As was first noted in the neonatal gene therapy studies, we observe that gene edited hepatocytes in the MMA mice treated as juveniles exhibit a growth advantage, which allows them to repopulate the liver slowly but dramatically by 8-10 months post treatment, and subsequently manifest a biochemical and enzymatic response. In conclusion, our results suggest that the benefit of AAV mediated nuclease-free gene editing of the Alb locus to treat MMA could potentially be therapeutic for older patients.
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Affiliation(s)
- Leah E Venturoni
- National Human Genome Research Institute, NIH, Bethesda, MD, United States of America
| | - Randy J Chandler
- National Human Genome Research Institute, NIH, Bethesda, MD, United States of America
| | - Jing Liao
- LogicBio Therapeutics, Lexington, MA, United States of America
| | - Victoria Hoffmann
- Office of Research Services, NIH, Bethesda, MD, United States of America
| | - Nikhil Ramesh
- LogicBio Therapeutics, Lexington, MA, United States of America
| | - Susana Gordo
- LogicBio Therapeutics, Lexington, MA, United States of America
| | - Nelson Chau
- LogicBio Therapeutics, Lexington, MA, United States of America
| | - Charles P Venditti
- National Human Genome Research Institute, NIH, Bethesda, MD, United States of America.
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Lee N, Kim D. Toxic Metabolites and Inborn Errors of Amino Acid Metabolism: What One Informs about the Other. Metabolites 2022; 12:metabo12060527. [PMID: 35736461 PMCID: PMC9231173 DOI: 10.3390/metabo12060527] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/20/2022] [Accepted: 05/30/2022] [Indexed: 12/01/2022] Open
Abstract
In inborn errors of metabolism, such as amino acid breakdown disorders, loss of function mutations in metabolic enzymes within the catabolism pathway lead to an accumulation of the catabolic intermediate that is the substrate of the mutated enzyme. In patients of such disorders, dietarily restricting the amino acid(s) to prevent the formation of these catabolic intermediates has a therapeutic or even entirely preventative effect. This demonstrates that the pathology is due to a toxic accumulation of enzyme substrates rather than the loss of downstream products. Here, we provide an overview of amino acid metabolic disorders from the perspective of the ‘toxic metabolites’ themselves, including their mechanism of toxicity and whether they are involved in the pathology of other disease contexts as well. In the research literature, there is often evidence that such metabolites play a contributing role in multiple other nonhereditary (and more common) disease conditions, and these studies can provide important mechanistic insights into understanding the metabolite-induced pathology of the inborn disorder. Furthermore, therapeutic strategies developed for the inborn disorder may be applicable to these nonhereditary disease conditions, as they involve the same toxic metabolite. We provide an in-depth illustration of this cross-informing concept in two metabolic disorders, methylmalonic acidemia and hyperammonemia, where the pathological metabolites methylmalonic acid and ammonia are implicated in other disease contexts, such as aging, neurodegeneration, and cancer, and thus there are opportunities to apply mechanistic or therapeutic insights from one disease context towards the other. Additionally, we expand our scope to other metabolic disorders, such as homocystinuria and nonketotic hyperglycinemia, to propose how these concepts can be applied broadly across different inborn errors of metabolism and various nonhereditary disease conditions.
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Devriendt N, Serrano G, Paepe D, Vandenabeele S, Stock E, de Rooster H. Persistent hypercobalaminemia three months after successful gradual attenuation of extrahepatic shunts in dogs: a prospective cohort study. BMC Vet Res 2022; 18:18. [PMID: 34991571 PMCID: PMC8734341 DOI: 10.1186/s12917-021-03123-1] [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: 07/17/2021] [Accepted: 12/13/2021] [Indexed: 11/10/2022] Open
Abstract
Background Deficiencies in vitamin A and D and disorders in the vitamin B complex are often present in people with chronic liver diseases. So far, the serum concentrations of these vitamins have not yet been studied in dogs with congenital extrahepatic portosystemic shunts (EHPSS), who also have some degree of liver dysfunction. The objective was to assess serum vitamin concentrations in dogs with EHPSS from diagnosis to complete closure. A prospective cohort study was performed using ten client-owned dogs with EHPSS, closed after gradual surgical attenuation. Serum concentrations of vitamin A, 25-hydroxyvitamin D, folic acid, cobalamin and methylmalonic acid (MMA) were measured at diagnosis prior to institution of medical therapy, prior to surgery, and three months after gradual attenuation and complete closure of the EHPSS. Results At diagnosis, median serum concentrations of vitamin A, 25-hydroxyvitamin D and folic acid were 18.2 μg/dL (8.8 - 79.5 μg/dL), 51.8 ng/mL (19.4 - 109.0 ng/mL), and 8.1 μg/L (5.2 - 14.5 μg/L), respectively, which increased significantly postoperatively (88.3 μg/dL (51.6 - 182.2 μg/dL, P=0.005), 89.6 ng/mL (49.3 - >150.0 ng/mL, P =0.005), and 14.8 μg/L (11.5 - 17.7 μg/L, P <0.001), respectively). Median serum cobalamin concentrations were 735.5 ng/L (470 - 1388 ng/L) at diagnosis and did not significantly decrease postoperatively (P =0.122). Both at diagnosis and three months postoperatively 7/10 dogs had hypercobalaminemia. Conclusions Serum concentrations of vitamin A, 25-hydroxyvitamin D and folic acid significantly increase after surgical attenuation. Nevertheless, persistent hypercobalaminemia is suggestive of ongoing liver dysfunction, despite successful surgery.
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Affiliation(s)
- Nausikaa Devriendt
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820, Merelbeke, Belgium.
| | - Gonçalo Serrano
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820, Merelbeke, Belgium
| | - Dominique Paepe
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820, Merelbeke, Belgium
| | - Sophie Vandenabeele
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820, Merelbeke, Belgium
| | - Emmelie Stock
- Department of Medical Imaging of Domestic Animals and Small Animal Orthopaedics, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820, Merelbeke, Belgium
| | - Hilde de Rooster
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820, Merelbeke, Belgium
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8
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Saleemani H, Egri C, Horvath G, Stockler‐Ipsiroglu S, Elango R. Dietary management and growth outcomes in children with propionic acidemia: A natural history study. JIMD Rep 2021; 61:67-75. [PMID: 34485020 PMCID: PMC8411103 DOI: 10.1002/jmd2.12234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 05/07/2021] [Accepted: 05/31/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Propionic acidemia (PROP) is an autosomal recessive inherited deficiency of propionyl-CoA carboxylase (PCC) which is involved in the catalytic breakdown of the amino acids valine, isoleucine, methionine, and threonine. PROP nutritional management is based on dietary protein restriction and use of special medical formulas which are free of the offending amino acids, but are enriched in leucine. The resulting imbalance among branched-chain amino acids negatively impacts plasma concentrations of valine and isoleucine, which might impact growth in children with PROP. OBJECTIVE AND METHODS Our primary objective was to describe dietary protein and calorie intake and their impact on long-term growth outcomes of four PROP patients. This was accomplished through a longitudinal retrospective chart review following the cohort from birth to 18 years. RESULTS All children (n = 4) had poor growth outcomes with persistently reduced height-for-age Z scores, and elevated weight and body mass index (BMI) Z scores. Energy intakes for all subjects were within 80% to 120% of the dietary reference intakes for age. All children had low intakes of intact protein compared with current guidelines and were supplemented with medical formula and single l-amino acids (valine and/or isoleucine), which led to the excess consumption of total protein. CONCLUSION Despite adequate total protein and energy intakes, all children had persistently low height Z scores. Restricted intact protein consumption together with the abundant use of medical formula could have affected overall growth. To optimize dietary management in patients with PROP, further research is needed to determine the optimal intake of medical formula relative to intact protein.
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Affiliation(s)
- Haneen Saleemani
- BC Children's Hospital Research Institute, BC Children's HospitalVancouverBritish ColumbiaCanada
- Faculty of Land and Food SystemsUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- Faculty of Applied Medical Sciences, Department of Clinical NutritionKing Abdulaziz UniversityJeddahSaudi Arabia
| | - Csilla Egri
- Division of Biochemical GeneticsBC Children's HospitalVancouverBritish ColumbiaCanada
- Department of PediatricsUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Gabriella Horvath
- Division of Biochemical GeneticsBC Children's HospitalVancouverBritish ColumbiaCanada
- Department of PediatricsUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Sylvia Stockler‐Ipsiroglu
- BC Children's Hospital Research Institute, BC Children's HospitalVancouverBritish ColumbiaCanada
- Division of Biochemical GeneticsBC Children's HospitalVancouverBritish ColumbiaCanada
- Department of PediatricsUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Rajavel Elango
- BC Children's Hospital Research Institute, BC Children's HospitalVancouverBritish ColumbiaCanada
- Faculty of Land and Food SystemsUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- Department of PediatricsUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- School of Population and Public Health, University of British ColumbiaVancouverBritish ColumbiaCanada
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9
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Evaluation of Body Composition, Physical Activity, and Food Intake in Patients with Inborn Errors of Intermediary Metabolism. Nutrients 2021; 13:nu13062111. [PMID: 34202936 PMCID: PMC8233825 DOI: 10.3390/nu13062111] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 06/11/2021] [Accepted: 06/18/2021] [Indexed: 12/12/2022] Open
Abstract
Children with inborn errors of intermediary metabolism (IEiM) must follow special diets that restrict their intake of essential nutrients and may compromise normal growth and development. We evaluated body composition, bone mineral density, physical activity, and food intake in IEiM patients undergoing dietary treatment. IEiM patients (n = 99) aged 5–19 years and healthy age- and sex-matched controls (n = 98) were recruited and underwent dual-energy X-ray absorptiometry to evaluate anthropometric characteristics and body composition. Data on food intake and physical activity were also collected using validated questionnaires. The height z-score was significantly lower in IEiM patients than controls (−0.28 vs. 0.15; p = 0.008), particularly in those with carbohydrate and amino acid metabolism disorders. Significant differences in adiposity were observed between patients and controls for the waist circumference z-score (−0.08 vs. −0.58; p = 0.005), but not the body mass index z-score (0.56 vs. 0.42; p = 0.279). IEiM patients had a significantly lower total bone mineral density (BMD) than controls (0.89 vs. 1.6; p = 0.001) and a higher risk of osteopenia (z-score < −2, 33.3% vs. 20.4%) and osteoporosis (z-score < −2.5, 7.1% vs. 0%), but none presented fractures. There was a significant positive correlation between natural protein intake and BMD. Our results indicate that patients with IEiM undergoing dietary treatment, especially those with amino acid and carbohydrate metabolism disorders, present alterations in body composition, including a reduced height, a tendency towards overweight and obesity, and a reduced BMD.
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Chandler RJ, Venturoni LE, Liao J, Hubbard BT, Schneller JL, Hoffmann V, Gordo S, Zang S, Ko C, Chau N, Chiang K, Kay MA, Barzel A, Venditti CP. Promoterless, Nuclease-Free Genome Editing Confers a Growth Advantage for Corrected Hepatocytes in Mice With Methylmalonic Acidemia. Hepatology 2021; 73:2223-2237. [PMID: 32976669 PMCID: PMC8252383 DOI: 10.1002/hep.31570] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/31/2020] [Accepted: 09/04/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Adeno-associated viral (AAV) gene therapy has shown great promise as an alternative treatment for metabolic disorders managed using liver transplantation, but remains limited by transgene loss and genotoxicity. Our study aims to test an AAV vector with a promoterless integrating cassette, designed to provide sustained hepatic transgene expression and reduced toxicity in comparison to canonical AAV therapy. APPROACH AND RESULTS Our AAV vector was designed to insert a methylmalonyl-CoA mutase (MMUT) transgene into the 3' end of the albumin locus and tested in mouse models of methylmalonic acidemia (MMA). After neonatal delivery, we longitudinally evaluated hepatic transgene expression, plasma levels of methylmalonate, and the MMA biomarker, fibroblast growth factor 21 (Fgf21), as well as integration of MMUT in the albumin locus. At necropsy, we surveyed for AAV-related hepatocellular carcinoma (HCC) in all treated MMA mice and control littermates. AAV-mediated genome editing of MMUT into the albumin locus resulted in permanent hepatic correction in MMA mouse models, which was accompanied by decreased levels of methylmalonate and Fgf21, and improved survival without HCC. With time, levels of transgene expression increased and methylmalonate progressively decreased, whereas the number of albumin-MMUT integrations and corrected hepatocytes in MMA mice increased, but not in similarly treated wild-type animals. Additionally, expression of MMUT in the setting of MMA conferred a selective growth advantage upon edited cells, which potentiates the therapeutic response. CONCLUSIONS In conclusion, our findings demonstrate that AAV-mediated, promoterless, nuclease-free genome editing at the albumin locus provides safe and durable therapeutic benefit in neonatally treated MMA mice.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Mark A. Kay
- Departments of Pediatrics and GeneticsStanford UniversityStanfordCA
| | - Adi Barzel
- Departments of Pediatrics and GeneticsStanford UniversityStanfordCA
- Department of Biochemistry and Molecular BiologyTel Aviv UniversityTel AvivIsrael
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11
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Mobarak A, Stockler S, Salvarinova R, Van Karnebeek C, Horvath G. Long term follow-up of the dietary intake in propionic acidemia. Mol Genet Metab Rep 2021; 27:100757. [PMID: 33981581 PMCID: PMC8082257 DOI: 10.1016/j.ymgmr.2021.100757] [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: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 11/09/2022] Open
Abstract
Long-term dietary management of Propionic acidemia (PA) includes natural protein restriction, and supplementation with medical formula enriched with leucine (Leu) and free of valine (Val), isoleucine (Ileu), methionine (Met), and threonine (Thr). As PA medical formulas have high leucine content, concerns started to arise regarding potential long-term health risks of unbalanced leucine intake. PA patients have chronically low plasma levels of Ile and Val, which led to the paradoxical need to supplement with propiogenic single amino acids (AAs). Our report takes a retrospective look at the long-term dietary management of four patients and its reflection on their plasma amino acids. The patients' total protein intake was above the recommended dietary allowance (RDA) and had a high Leu/Val and Leu/Ile intake ratios in diet. Despite adequate total protein intake, patients had chronically low plasma Ile and Val and a high plasma Leu/Val and Leu/Ile ratios, which could be attributed to high Leu intake. We conclude that the best approach to PA dietary management is to only use medical formula with patients not meeting their RDA through natural protein, and to monitor plasma amino acids levels closely.
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Affiliation(s)
- A. Mobarak
- Department of Pediatrics, Division of Biochemical Genetics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
- Department of Pediatrics, Medical Genetics and Biochemical Genetics Unit, Faculty of Medicine, Tanta University, Egypt
| | - S. Stockler
- Department of Pediatrics, Division of Biochemical Genetics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - R. Salvarinova
- Department of Pediatrics, Division of Biochemical Genetics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - C. Van Karnebeek
- Department of Pediatrics, Radboud Centre for Mitochondrial Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
- Department of Pediatrics, Centre for Molecular Medicine & Therapeutics, Vancouver, Canada
| | - G. Horvath
- Department of Pediatrics, Division of Biochemical Genetics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
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12
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Severity modeling of propionic acidemia using clinical and laboratory biomarkers. Genet Med 2021; 23:1534-1542. [PMID: 34007002 PMCID: PMC8354856 DOI: 10.1038/s41436-021-01173-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 03/26/2021] [Accepted: 03/29/2021] [Indexed: 01/18/2023] Open
Abstract
Purpose To conduct a proof-of-principle study to identify subtypes of propionic acidemia (PA) and associated biomarkers. Methods Data from a clinically diverse PA patient population (https://clinicaltrials.gov/ct2/show/NCT02890342) were used to train and test machine learning models, identify PA-relevant biomarkers, and perform validation analysis using data from liver-transplanted participants. k-Means clustering was used to test for the existence of PA subtypes. Expert knowledge was used to define PA subtypes (mild and severe). Given expert classification, supervised machine learning (support vector machine with a polynomial kernel, svmPoly) performed dimensional reduction to define relevant features of each PA subtype. Results Forty participants enrolled in the study; five underwent liver transplant. Analysis with k-means clustering indicated that several PA subtypes may exist on the biochemical continuum. The conventional PA biomarkers, plasma total 2-methylctirate and propionylcarnitine, were not statistically significantly different between nontransplanted and transplanted participants motivating us to search for other biomarkers. Unbiased dimensional reduction using svmPoly revealed that plasma transthyretin, alanine:serine ratio, GDF15, FGF21, and in vivo 1-13C-propionate oxidation, play roles in defining PA subtypes. Conclusion Support vector machine prioritized biomarkers that helped classify propionic acidemia patients according to severity subtypes, with important ramifications for future clinical trials and management of PA. Graphical Abstract ![]()
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Forny P, Hörster F, Ballhausen D, Chakrapani A, Chapman KA, Dionisi‐Vici C, Dixon M, Grünert SC, Grunewald S, Haliloglu G, Hochuli M, Honzik T, Karall D, Martinelli D, Molema F, Sass JO, Scholl‐Bürgi S, Tal G, Williams M, Huemer M, Baumgartner MR. Guidelines for the diagnosis and management of methylmalonic acidaemia and propionic acidaemia: First revision. J Inherit Metab Dis 2021; 44:566-592. [PMID: 33595124 PMCID: PMC8252715 DOI: 10.1002/jimd.12370] [Citation(s) in RCA: 115] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 02/03/2021] [Accepted: 02/15/2021] [Indexed: 12/13/2022]
Abstract
Isolated methylmalonic acidaemia (MMA) and propionic acidaemia (PA) are rare inherited metabolic diseases. Six years ago, a detailed evaluation of the available evidence on diagnosis and management of these disorders has been published for the first time. The article received considerable attention, illustrating the importance of an expert panel to evaluate and compile recommendations to guide rare disease patient care. Since that time, a growing body of evidence on transplant outcomes in MMA and PA patients and use of precursor free amino acid mixtures allows for updates of the guidelines. In this article, we aim to incorporate this newly published knowledge and provide a revised version of the guidelines. The analysis was performed by a panel of multidisciplinary health care experts, who followed an updated guideline development methodology (GRADE). Hence, the full body of evidence up until autumn 2019 was re-evaluated, analysed and graded. As a result, 21 updated recommendations were compiled in a more concise paper with a focus on the existing evidence to enable well-informed decisions in the context of MMA and PA patient care.
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Affiliation(s)
- Patrick Forny
- Division of Metabolism and Children's Research CenterUniversity Children's Hospital Zurich, University of ZurichZurichSwitzerland
| | - Friederike Hörster
- Division of Neuropediatrics and Metabolic MedicineUniversity Hospital HeidelbergHeidelbergGermany
| | - Diana Ballhausen
- Paediatric Unit for Metabolic Diseases, Department of Woman‐Mother‐ChildUniversity Hospital LausanneLausanneSwitzerland
| | - Anupam Chakrapani
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust and Institute for Child HealthNIHR Biomedical Research Center (BRC), University College LondonLondonUK
| | - Kimberly A. Chapman
- Rare Disease Institute, Children's National Health SystemWashingtonDistrict of ColumbiaUSA
| | - Carlo Dionisi‐Vici
- Division of Metabolism, Department of Pediatric SpecialtiesBambino Gesù Children's HospitalRomeItaly
| | - Marjorie Dixon
- Dietetics, Great Ormond Street Hospital for Children NHS Foundation TrustLondonUK
| | - Sarah C. Grünert
- Department of General Paediatrics, Adolescent Medicine and Neonatology, Medical Centre‐University of FreiburgFaculty of MedicineFreiburgGermany
| | - Stephanie Grunewald
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust and Institute for Child HealthNIHR Biomedical Research Center (BRC), University College LondonLondonUK
| | - Goknur Haliloglu
- Department of Pediatrics, Division of Pediatric NeurologyHacettepe University Children's HospitalAnkaraTurkey
| | - Michel Hochuli
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, InselspitalBern University Hospital and University of BernBernSwitzerland
| | - Tomas Honzik
- Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of MedicineCharles University and General University Hospital in PraguePragueCzech Republic
| | - Daniela Karall
- Department of Paediatrics I, Inherited Metabolic DisordersMedical University of InnsbruckInnsbruckAustria
| | - Diego Martinelli
- Division of Metabolism, Department of Pediatric SpecialtiesBambino Gesù Children's HospitalRomeItaly
| | - Femke Molema
- Department of Pediatrics, Center for Lysosomal and Metabolic DiseasesErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Jörn Oliver Sass
- Department of Natural Sciences & Institute for Functional Gene Analytics (IFGA)Bonn‐Rhein Sieg University of Applied SciencesRheinbachGermany
| | - Sabine Scholl‐Bürgi
- Department of Paediatrics I, Inherited Metabolic DisordersMedical University of InnsbruckInnsbruckAustria
| | - Galit Tal
- Metabolic Unit, Ruth Rappaport Children's HospitalRambam Health Care CampusHaifaIsrael
| | - Monique Williams
- Department of Pediatrics, Center for Lysosomal and Metabolic DiseasesErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Martina Huemer
- Division of Metabolism and Children's Research CenterUniversity Children's Hospital Zurich, University of ZurichZurichSwitzerland
- Department of PaediatricsLandeskrankenhaus BregenzBregenzAustria
| | - Matthias R. Baumgartner
- Division of Metabolism and Children's Research CenterUniversity Children's Hospital Zurich, University of ZurichZurichSwitzerland
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14
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1- 13C-propionate breath testing as a surrogate endpoint to assess efficacy of liver-directed therapies in methylmalonic acidemia (MMA). Genet Med 2021; 23:1522-1533. [PMID: 33820958 PMCID: PMC8354855 DOI: 10.1038/s41436-021-01143-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/25/2021] [Accepted: 03/01/2021] [Indexed: 12/15/2022] Open
Abstract
PURPOSE To develop a safe and noninvasive in vivo assay of hepatic propionate oxidative capacity. METHODS A modified 1-13C-propionate breath test was administered to 57 methylmalonic acidemia (MMA) subjects, including 19 transplant recipients, and 16 healthy volunteers. Isotopomer enrichment (13CO2/12CO2) was measured in exhaled breath after an enteral bolus of sodium-1-13C-propionate, and normalized for CO2 production. 1-13C-propionate oxidation was then correlated with clinical, laboratory, and imaging parameters collected via a dedicated natural history protocol. RESULTS Lower propionate oxidation was observed in patients with the severe mut0 and cblB subtypes of MMA, but was near normal in those with the cblA and mut- forms of the disorder. Liver transplant recipients demonstrated complete restoration of 1-13C-propionate oxidation to control levels. 1-13C-propionate oxidation correlated with cognitive test result, growth indices, bone mineral density, renal function, and serum biomarkers. Test repeatability was robust in controls and in MMA subjects (mean coefficient of variation 6.9% and 12.8%, respectively), despite widely variable serum methylmalonic acid concentrations in the patients. CONCLUSION Propionate oxidative capacity, as measured with 1-13C-propionate breath testing, predicts disease severity and clinical outcomes, and could be used to assess the therapeutic effects of liver-targeted genomic therapies for MMA and related disorders of propionate metabolism. TRIAL REGISTRATION This clinical study is registered in www.clinicaltrials.gov with the ID: NCT00078078. Study URL: http://clinicaltrials.gov/ct2/show/NCT00078078.
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15
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Molema F, Haijes HA, Janssen MC, Bosch AM, van Spronsen FJ, Mulder MF, Verhoeven-Duif NM, Jans JJM, van der Ploeg AT, Wagenmakers MA, Rubio-Gozalbo ME, Brouwers MCGJ, de Vries MC, Fuchs S, Langendonk JG, Rizopoulos D, van Hasselt PM, Williams M. High protein prescription in methylmalonic and propionic acidemia patients and its negative association with long-term outcome. Clin Nutr 2020; 40:3622-3630. [PMID: 33451859 DOI: 10.1016/j.clnu.2020.12.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 12/16/2020] [Accepted: 12/20/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Methylmalonic acidemia (MMA) and propionic acidemia (PA) are inborn errors of metabolism. While survival of MMA and PA patients has improved in recent decades, long-term outcome is still unsatisfactory. A protein restricted diet is the mainstay for treatment. Additional amino acid mixtures (AAM) can be prescribed if natural protein is insufficient. It is unknown if dietary treatment can have an impact on outcome. DESIGN We performed a nationwide retrospective cohort study and evaluated both longitudinal dietary treatment and clinical course of Dutch MMA and PA patients. Protein prescription was compared to the recommended daily allowances (RDA); the safe level of protein intake as provided by the World Health Organization. The association of longitudinal dietary treatment with long-term outcome was evaluated. RESULTS The cohort included 76 patients with a median retrospective follow-up period of 15 years (min-max: 0-48 years) and a total of 1063 patient years on a protein restricted diet. Natural protein prescription exceeded the RDA in 37% (470/1287) of all prescriptions and due to AAM prescription, the total protein prescription exceeded RDA in 84% (1070/1277). Higher protein prescriptions were associated with adverse outcomes in severely affected patients. In PA early onset patients a higher natural protein prescription was associated with more frequent AMD. In MMA vitamin B12 unresponsive patients, both a higher total protein prescription and AAM protein prescription were associated with more mitochondrial complications. A higher AAM protein prescription was associated with an increased frequency of cognitive impairment in the entire. CONCLUSION Protein intake in excess of recommendations is frequent and is associated with poor outcome.
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Affiliation(s)
- F Molema
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - H A Haijes
- Section Metabolic Diagnostics, Department of Genetics, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands; Section Metabolic Diseases, Department of Child Health, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - M C Janssen
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - A M Bosch
- Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - F J van Spronsen
- Section of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - M F Mulder
- Department of Pediatrics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - N M Verhoeven-Duif
- Section Metabolic Diagnostics, Department of Genetics, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - J J M Jans
- Section Metabolic Diagnostics, Department of Genetics, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - A T van der Ploeg
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - M A Wagenmakers
- Department of Internal Medicine, Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - M E Rubio-Gozalbo
- Department of Pediatrics and Clinical Genetics, Maastricht University Medical Center, Maastricht University, Maastricht, the Netherlands
| | - M C G J Brouwers
- Department of Internal Medicine, Division of Endocrinology and Metabolic Disease, Maastricht University Medical Center, Maastricht, the Netherlands
| | - M C de Vries
- Department of Pediatrics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - S Fuchs
- Section Metabolic Diseases, Department of Child Health, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - J G Langendonk
- Department of Internal Medicine, Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - D Rizopoulos
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - P M van Hasselt
- Section Metabolic Diseases, Department of Child Health, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - M Williams
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, Rotterdam, the Netherlands.
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Proctor EC, Turton N, Boan EJ, Bennett E, Philips S, Heaton RA, Hargreaves IP. The Effect of Methylmalonic Acid Treatment on Human Neuronal Cell Coenzyme Q 10 Status and Mitochondrial Function. Int J Mol Sci 2020; 21:E9137. [PMID: 33266298 PMCID: PMC7730949 DOI: 10.3390/ijms21239137] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 11/26/2020] [Accepted: 11/27/2020] [Indexed: 12/26/2022] Open
Abstract
Methylmalonic acidemia is an inborn metabolic disease of propionate catabolism, biochemically characterized by accumulation of methylmalonic acid (MMA) to millimolar concentrations in tissues and body fluids. However, MMA's role in the pathophysiology of the disorder and its status as a "toxic intermediate" is unclear, despite evidence for its ability to compromise antioxidant defenses and induce mitochondrial dysfunction. Coenzyme Q10 (CoQ10) is a prominent electron carrier in the mitochondrial respiratory chain (MRC) and a lipid-soluble antioxidant which has been reported to be deficient in patient-derived fibroblasts and renal tissue from an animal model of the disease. However, at present, it is uncertain which factors are responsible for inducing this CoQ10 deficiency or the effect of this deficit in CoQ10 status on mitochondrial function. Therefore, in this study, we investigated the potential of MMA, the principal metabolite that accumulates in methylmalonic acidemia, to induce a cellular CoQ10 deficiency. In view of the severe neurological presentation of patients with this condition, human neuroblastoma SH-SY5Y cells were used as a neuronal cell model for this investigation. Following treatment with pathological concentrations of MMA (>0.5 mM), we found a significant (p = 0.0087) ~75% reduction in neuronal cell CoQ10 status together with a significant (p = 0.0099) decrease in MRC complex II-III activity at higher concentrations (>2 mM). The deficits in neuronal CoQ10 status and MRC complex II-III activity were associated with a loss of cell viability. However, no significant impairment of mitochondrial membrane potential (ΔΨm) was detectable. These findings indicate the potential of pathological concentrations of MMA to induce a neuronal cell CoQ10 deficiency with an associated loss of MRC complex II-III activity. However, in the absence of an impairment of ΔΨm, the contribution this potential deficit in cellular CoQ10 status makes towards the disease pathophysiology methylmalonic acidemia has yet to be fully elucidated.
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Affiliation(s)
- Emma C. Proctor
- Department of Biochemistry, University of Warwick, Coventry CV4 7AL, UK;
| | - Nadia Turton
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool L3 3AF, UK; (N.T.); (E.J.B.); (E.B.); (R.A.H.)
| | - Elle Jo Boan
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool L3 3AF, UK; (N.T.); (E.J.B.); (E.B.); (R.A.H.)
| | - Emily Bennett
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool L3 3AF, UK; (N.T.); (E.J.B.); (E.B.); (R.A.H.)
| | - Suzannah Philips
- Department of Clinical Biochemistry, The Royal Liverpool University Hospital, Royal Liverpool and Broadgreen NHS Trust, Prescot Street, Liverpool L7 8XP, UK;
| | - Robert A. Heaton
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool L3 3AF, UK; (N.T.); (E.J.B.); (E.B.); (R.A.H.)
| | - Iain P. Hargreaves
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool L3 3AF, UK; (N.T.); (E.J.B.); (E.B.); (R.A.H.)
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Francini-Pesenti F, Gugelmo G, Lenzini L, Vitturi N. Nutrient Intake and Nutritional Status in Adult Patients with Inherited Metabolic Diseases Treated with Low-Protein Diets: A Review on Urea Cycle Disorders and Branched Chain Organic Acidemias. Nutrients 2020; 12:E3331. [PMID: 33138136 PMCID: PMC7693747 DOI: 10.3390/nu12113331] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 10/23/2020] [Accepted: 10/26/2020] [Indexed: 12/31/2022] Open
Abstract
Low-protein diets (LPDs) are the main treatment for urea cycle disorders (UCDs) and organic acidemias (OAs). In most cases, LPDs start in childhood and must be continued into adulthood. The improved life expectancy of patients with UCDs and OAs raises the question of their consequences on nutritional status in adult subjects. As this topic has so far received little attention, we conducted a review of scientific studies that investigated the nutrient intake and nutritional status in adult patients with UCDs and branched chain organic acidemias (BCOAs) on LPD. METHODS The literature search was conducted in PubMed/MEDLINE, Scopus, EMBASE and Google Scholar from 1 January 2000 to 31 May 2020, focusing on nutrient intake and nutritional status in UCD and OA adult patients. RESULTS Despite protein restriction is recommended as the main treatment for UCDs and OAs, in these patients, protein intake ranges widely, with many patients who do not reach safety levels. When evaluated, micronutrient intake resulted below recommended values in some patients. Lean body mass resulted in most cases lower than normal range while fat body mass (FM) was often found normal or higher than the controls or reference values. Protein intake correlated inversely with FM both in adult and pediatric UCD patients. CONCLUSIONS The clinical management of adult patients with UCDs and BCOAs should include an accurate assessment of the nutritional status and body composition. However, as little data is still available on this topic, further studies are needed to better clarify the effects of LPDs on nutritional status in adult UCD and BCOA patients.
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Affiliation(s)
- Francesco Francini-Pesenti
- Department of Medicine-DIMED, University of Padova, Division of Clinical Nutrition, University Hospital, 35128 Padova, Italy; (F.F.-P.); (G.G.)
| | - Giorgia Gugelmo
- Department of Medicine-DIMED, University of Padova, Division of Clinical Nutrition, University Hospital, 35128 Padova, Italy; (F.F.-P.); (G.G.)
| | - Livia Lenzini
- Department of Medicine-DIMED, University of Padova, Hypertension Unit, University Hospital, 35128 Padova, Italy;
| | - Nicola Vitturi
- Department of Medicine-DIMED, Division of Metabolic Diseases, University Hospital, 35128 Padova, Italy
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18
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Bernstein LE, Burns C, Drumm M, Gaughan S, Sailer M, Baker II PR. Impact on Isoleucine and Valine Supplementation When Decreasing Use of Medical Food in the Nutritional Management of Methylmalonic Acidemia. Nutrients 2020; 12:E473. [PMID: 32069872 PMCID: PMC7071216 DOI: 10.3390/nu12020473] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/30/2020] [Accepted: 02/06/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Methylmalonic acidemia (MMA) is an autosomal recessive disorder treated with precursor-free medical food while limiting natural protein. This retrospective chart review was to determine if there was a relationship between medical food, valine (VAL) and/or isoleucine (ILE) supplementation, total protein intake, and plasma amino acid profiles. Methods: A chart review, of patients aged 31 days or older with MMA treated with dietary intervention and supplementation of VAL and/or ILE and followed at the Children's Hospital Colorado Inherited Metabolic Diseases Clinic. Dietary prescriptions and plasma amino acid concentrations were obtained at multiple time points. RESULTS Baseline mean total protein intake for five patients was 198% of Recommended Dietary Allowance (RDA) with 107% natural protein and 91% medical food. Following intervention, total protein intake (p = 0.0357), protein from medical food (p = 0.0142), and leucine (LEU) from medical food (p = 0.0276) were lower, with no significant change in natural protein intake (p = 0.2036). At baseline, 80% of patients received VAL supplementation and 100% received ILE supplementation. After intervention, only one of the cohort remained on supplementation. There was no statistically significant difference in plasma propiogenic amino acid concentrations. CONCLUSIONS Decreased intake of LEU from medical food allowed for discontinuation of amino acid supplementation, while meeting the RDA for protein.
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Affiliation(s)
| | | | | | - Sommer Gaughan
- Department of Pediatrics Section of Clinical Genetics and Metabolism, Aurora, Children’s Hospital Colorado, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA; (L.E.B.); (M.D.)
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19
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Brambilla A, Bianchi ML, Cancello R, Galimberti C, Gasperini S, Pretese R, Rigoldi M, Tursi S, Parini R. Resting energy expenditure in argininosuccinic aciduria and in other urea cycle disorders. J Inherit Metab Dis 2019; 42:1105-1117. [PMID: 31056765 DOI: 10.1002/jimd.12108] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 04/28/2019] [Accepted: 04/30/2019] [Indexed: 12/30/2022]
Abstract
No data are available on the specific energy needs of patients affected with Urea Cycle disorders (UCD) and especially argininosuccinic aciduria (ASA). In our experience, ASA patients tend to develop central adiposity and hypertriglyceridemia when treated with apparently adequate energy intake, while the other UCD do not. The aim of this study was to evaluate anthropometric parameters, body composition, risk of metabolic syndrome (MS) and resting energy expenditure (REE), both by indirect calorimetry (IC) and predictive equations, in UCD patients. Hypertension (5/13), pathological waist circumference-to-height ratio (WtHr) (6/13), hypertriglyceridemia (12/13), reduced HDL cholesterol (12/13), and MS (5/13) were found in ASA group. In the ASA cohort, the mean and median IC-REE were 88% of what was predicted by Food and Agriculture Organization of the United Nations and Harris-Benedict equations. The "other UCD" cohort did not show hypertension, dyslipidaemia nor MS; IC-REE was similar to the REE predicted by equations. A significant difference was seen for the presence of hypertension, dyslipidaemia, pathological WtHr, MS and IC-REE/predictive equations-REE in the two cohorts. ASA patients have a risk of overfeeding if their energy requirement is not assessed individually with IC. Excessive energy intake might increase the cardiovascular risk of ASA patients. We suggest to test ASA individuals with IC every year if the patient is sufficiently collaborative. We speculate that most of the features seen in ASA patients might depend on an imbalance of Krebs cycle. Further studies are needed to verify this hypothesis.
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Affiliation(s)
- Alessandra Brambilla
- Department of Pediatrics, Fondazione MBBM, ATS Monza, University Hospital San Gerardo, Monza, Italy
| | - Maria L Bianchi
- Bone Metabolism Unit, Istituto Auxologico Italiano, Milano, Italy
| | | | - Cinzia Galimberti
- Department of Pediatrics, Fondazione MBBM, ATS Monza, University Hospital San Gerardo, Monza, Italy
| | - Serena Gasperini
- Department of Pediatrics, Fondazione MBBM, ATS Monza, University Hospital San Gerardo, Monza, Italy
| | - Roberta Pretese
- Department of Pediatrics, Fondazione MBBM, ATS Monza, University Hospital San Gerardo, Monza, Italy
| | - Miriam Rigoldi
- Department of Medical Genetics, Rare Disease Center, ASST San Gerardo, Monza, Italy
| | - Serena Tursi
- Department of Pediatrics, Fondazione MBBM, ATS Monza, University Hospital San Gerardo, Monza, Italy
| | - Rossella Parini
- Department of Pediatrics, Fondazione MBBM, ATS Monza, University Hospital San Gerardo, Monza, Italy
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20
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Haijes HA, Jans JJM, Tas SY, Verhoeven-Duif NM, van Hasselt PM. Pathophysiology of propionic and methylmalonic acidemias. Part 1: Complications. J Inherit Metab Dis 2019; 42:730-744. [PMID: 31119747 DOI: 10.1002/jimd.12129] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/18/2019] [Accepted: 05/21/2019] [Indexed: 12/14/2022]
Abstract
Over the last decades, advances in clinical care for patients suffering from propionic acidemia (PA) and isolated methylmalonic acidemia (MMA) have resulted in improved survival. These advances were possible thanks to new pathophysiological insights. However, patients may still suffer from devastating complications which largely determine the unsatisfying overall outcome. To optimize our treatment strategies, better insight in the pathophysiology of complications is needed. Here, we perform a systematic data-analysis of cohort studies and case-reports on PA and MMA. For each of the prevalent and rare complications, we summarize the current hypotheses and evidence for the underlying pathophysiology of that complication. A common hypothesis on pathophysiology of many of these complications is that mitochondrial impairment plays a major role. Assuming that complications in which mitochondrial impairment may play a role are overrepresented in monogenic mitochondrial diseases and, conversely, that complications in which mitochondrial impairment does not play a role are underrepresented in mitochondrial disease, we studied the occurrence of the complications in PA and MMA in mitochondrial and other monogenic diseases, using data provided by the Human Phenotype Ontology. Lastly, we combined this with evidence from literature to draw conclusions on the possible role of mitochondrial impairment in each complication. Altogether, this review provides a comprehensive overview on what we, to date, do and do not understand about pathophysiology of complications occurring in PA and MMA and about the role of mitochondrial impairment herein.
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Affiliation(s)
- Hanneke A Haijes
- Section Metabolic Diagnostics, Department of Genetics, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
- Section Metabolic Diseases, Department of Child Health, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Judith J M Jans
- Section Metabolic Diagnostics, Department of Genetics, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Simone Y Tas
- Section Metabolic Diseases, Department of Child Health, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Nanda M Verhoeven-Duif
- Section Metabolic Diagnostics, Department of Genetics, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Peter M van Hasselt
- Section Metabolic Diseases, Department of Child Health, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
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21
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Jiang YZ, Sun LY. The Value of Liver Transplantation for Methylmalonic Acidemia. Front Pediatr 2019; 7:87. [PMID: 30949461 PMCID: PMC6437036 DOI: 10.3389/fped.2019.00087] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 02/28/2019] [Indexed: 12/14/2022] Open
Abstract
Introduction: MMA is a rare autosomal recessive disorder with the manifestation of recurrent and severe episodes of acute metabolic decompensation or a variety of long-term complications that require timely treatment. While conventional long-term medical and dietary management cannot prevent rapid progression of conditions in patients with severe complications, LT, or CKLT has become an option. Methods: We reviewed the literature for MMA patients undergoing LT/CKLT published since 2006, and data on metabolic decompensation status, protein dietary, neurological damage, renal insufficiency, and developmental delay before and after transplantations were compared to evaluate the clinical value of the procedure in the treatment of MMA. Results: To date, some successful LTs/CKLT procedures have prolonged survival and resulted in better quality of life in patients (lowered urine/plasma MMA levels but still much higher than normal, reduced onset of metabolic stroke, occasional improved developmental delay, and relaxed protein diet), although these procedures cannot reverse neurological damage or thoroughly stop the progress of complications, such as renal dysfunction. Conclusion: LT is the only effective treatment for MMA patients with recurrent metabolic decompensation. However, it is still possible that neurological and renal damage remains irreversible. Metabolism-correcting medications should be administered even after surgery.
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Affiliation(s)
- Yi-Zhou Jiang
- Intensive Care Unit, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Liver Transplantation Center, Clinical Center for Pediatric Liver Transplantation, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Li-Ying Sun
- Intensive Care Unit, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Liver Transplantation Center, Clinical Center for Pediatric Liver Transplantation, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Tolerance Induction and Organ Protection in Transplantation, Beijing, China
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22
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Wang SJ, Yan CZ, Wen B, Zhao YY. Clinical feature and outcome of late-onset cobalamin C disease patients with neuropsychiatric presentations: a Chinese case series. Neuropsychiatr Dis Treat 2019; 15:549-555. [PMID: 30863077 PMCID: PMC6391119 DOI: 10.2147/ndt.s196924] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE The Cobalamin C (cblC) disease is an inborn error of cobalamin metabolism. Late-onset cblC disease was diagnosed in patients having overt symptoms after 4 years of age. The late-onset cblC disease patients were rare and easily misdiagnosed. This study analyzed the clinical presentations, gene mutations, and treatments of Chinese patients with late-onset cblC disease. METHODS The clinical data of 26 Han Chinese patients diagnosed with late-onset cblC disease were retrospectively analyzed. All patients underwent serum homocysteine level exam, urine concentrations of organic acids measurement, neuroimaging scans, gene analysis, and treatments evaluations. RESULTS The mean age at disease onset and diagnosis was 17.8±7.0 years. The most frequent neuropsychiatric disturbances were lower limb weakness (50%), psychiatric disturbances (46.2%), and gait instability (42.3%). The mean methylmalonic acid level in urine was 107.4±56.6 μmol/L, and mean serum total homocysteine was 105.4±41.0 μmol/L. The most common abnormal radioimaging changes were observed in the spinal cord (88%) and brain (32%). Scoliosis was detected in 85.7% of patients. The methylmalonic aciduria and homocystinuria type C protein gene analysis showed that c.482G>A (57.7%) and c.609G>A (34.6%) mutations were the most frequent genotypes. After treatments with hydroxycobalamin, betaine, folic acid, L-carnitine, and compound vitamin B, the clinical features and biochemical parameters of patients with late-onset cblC disease were found to be alleviated. CONCLUSION In our late-onset cblC disease cases, lower limb weakness, psychiatric disturbances, and gait instability were the most frequent manifestations. Patients responded well to the drug treatments with hydrocobalamin and betaine. When juvenile or adult patients with hyperhomocysteinemia present with neurological symptoms, cblC disease needs to be considered.
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Affiliation(s)
- Sheng-Jun Wang
- Department of Neurology, Qilu Hospital, Shandong University, Jinan, China,
| | - Chuan-Zhu Yan
- Department of Neurology, Qilu Hospital, Shandong University, Jinan, China,
| | - Bing Wen
- Department of Neurology, Qilu Hospital, Shandong University, Jinan, China,
| | - Yu-Ying Zhao
- Department of Neurology, Qilu Hospital, Shandong University, Jinan, China,
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23
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Manoli I, Sysol JR, Epping MW, Li L, Wang C, Sloan JL, Pass A, Gagné J, Ktena YP, Li L, Trivedi NS, Ouattara B, Zerfas PM, Hoffmann V, Abu-Asab M, Tsokos MG, Kleiner DE, Garone C, Cusmano-Ozog K, Enns GM, Vernon HJ, Andersson HC, Grunewald S, Elkahloun AG, Girard CL, Schnermann J, DiMauro S, Andres-Mateos E, Vandenberghe LH, Chandler RJ, Venditti CP. FGF21 underlies a hormetic response to metabolic stress in methylmalonic acidemia. JCI Insight 2018; 3:124351. [PMID: 30518688 DOI: 10.1172/jci.insight.124351] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 10/24/2018] [Indexed: 12/17/2022] Open
Abstract
Methylmalonic acidemia (MMA), an organic acidemia characterized by metabolic instability and multiorgan complications, is most frequently caused by mutations in methylmalonyl-CoA mutase (MUT). To define the metabolic adaptations in MMA in acute and chronic settings, we studied a mouse model generated by transgenic expression of Mut in the muscle. Mut-/-;TgINS-MCK-Mut mice accurately replicate the hepatorenal mitochondriopathy and growth failure seen in severely affected patients and were used to characterize the response to fasting. The hepatic transcriptome in MMA mice was characterized by the chronic activation of stress-related pathways and an aberrant fasting response when compared with controls. A key metabolic regulator, Fgf21, emerged as a significantly dysregulated transcript in mice and was subsequently studied in a large patient cohort. The concentration of plasma FGF21 in MMA patients correlated with disease subtype, growth indices, and markers of mitochondrial dysfunction but was not affected by renal disease. Restoration of liver Mut activity, by transgenesis and liver-directed gene therapy in mice or liver transplantation in patients, drastically reduced plasma FGF21 and was associated with improved outcomes. Our studies identify mitocellular hormesis as a hepatic adaptation to metabolic stress in MMA and define FGF21 as a highly predictive disease biomarker.
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Affiliation(s)
- Irini Manoli
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, NIH, Bethesda, Maryland, USA
| | - Justin R Sysol
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, NIH, Bethesda, Maryland, USA
| | - Madeline W Epping
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, NIH, Bethesda, Maryland, USA
| | - Lina Li
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, NIH, Bethesda, Maryland, USA
| | - Cindy Wang
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, NIH, Bethesda, Maryland, USA
| | - Jennifer L Sloan
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, NIH, Bethesda, Maryland, USA
| | - Alexandra Pass
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, NIH, Bethesda, Maryland, USA
| | - Jack Gagné
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, NIH, Bethesda, Maryland, USA
| | - Yiouli P Ktena
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, NIH, Bethesda, Maryland, USA
| | - Lingli Li
- Kidney Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland, USA
| | - Niraj S Trivedi
- Genome Technology Branch, National Human Genome Research Institute, NIH, Bethesda, Maryland, USA
| | - Bazoumana Ouattara
- Sherbrooke Research and Development Centre, Agriculture and Agri-Food Canada, Sherbrooke, Quebec, Canada.,Péléforo Gbon Coulibaly University, Korhogo, Ivory Coast
| | | | | | - Mones Abu-Asab
- Ultrastructural Pathology Section, Center for Cancer Research, NIH, Bethesda, Maryland, USA
| | - Maria G Tsokos
- Ultrastructural Pathology Section, Center for Cancer Research, NIH, Bethesda, Maryland, USA
| | - David E Kleiner
- Laboratory of Pathology, National Cancer Institute, NIH, Bethesda, Maryland, USA
| | - Caterina Garone
- Department of Neurology, Columbia University Medical Center, New York, New York, USA
| | | | - Gregory M Enns
- Division of Medical Genetics, Stanford University, Stanford, California, USA
| | - Hilary J Vernon
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Hans C Andersson
- Hayward Genetics Center, Tulane University Medical School, New Orleans, Louisiana, USA
| | - Stephanie Grunewald
- Department of Pediatric Metabolic Medicine, Great Ormond Street Hospital for Children Foundation Trust, Institute of Child Health, UCL, London, United Kingdom
| | - Abdel G Elkahloun
- Genome Technology Branch, National Human Genome Research Institute, NIH, Bethesda, Maryland, USA
| | - Christiane L Girard
- Sherbrooke Research and Development Centre, Agriculture and Agri-Food Canada, Sherbrooke, Quebec, Canada
| | - Jurgen Schnermann
- Kidney Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland, USA
| | - Salvatore DiMauro
- Department of Neurology, Columbia University Medical Center, New York, New York, USA
| | - Eva Andres-Mateos
- Grousbeck Gene Therapy Center, Schepens Eye Research Institute and Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.,Ocular Genomics Institute, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Luk H Vandenberghe
- Grousbeck Gene Therapy Center, Schepens Eye Research Institute and Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.,Ocular Genomics Institute, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA.,Harvard Stem Cell Institute, Harvard University, Cambridge, Massachusetts, USA.,Broad Institute of Harvard and MIT, Cambridge, Massachusetts, USA
| | - Randy J Chandler
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, NIH, Bethesda, Maryland, USA
| | - Charles P Venditti
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, NIH, Bethesda, Maryland, USA
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24
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Shafaat M, Alaee MR, Rahmanifar A, Setoodeh A, Razzaghy-Azar M, Bagherian H, Bagheri SD, Zafarghandi Motlagh F, Hashemi M, Abiri M, Zeinali S. Autozygosity mapping of methylmalonic acidemia associated genes by short tandem repeat markers facilitates the identification of five novel mutations in an Iranian patient cohort. Metab Brain Dis 2018; 33:1689-1697. [PMID: 30022420 DOI: 10.1007/s11011-018-0277-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 06/20/2018] [Indexed: 11/30/2022]
Abstract
Isolated Methylmalonic acidemia/aciduria (MMA) is a group of inborn errors of metabolism disease which is caused by defect in methylmalonyl-CoA mutase (MCM) enzyme. The enzyme has a key function in the catabolism of branched chain amino acids (BCAA, isoleucine, and valine), methionine, and threonine. MCM is encoded by a single gene named "MUT". Other subtypes of MMA are caused by mutations in cblA (encoded by MMAA) and cblB (encoded by MMAB), which is involved in the synthesis of methylmalonyl-coenzyme A cofactor. Different types of mutations have been identified as the cause of MMA. However, the mutation spectrum of MMA in Iran has not been studied so far. Here, we aimed to investigate the MMA causative mutations in the Iranian population. Using STR (Short Tandem Repeat) markers, we performed autozygosity mapping to identify the potential pathogenic variants in 11 patients with clinical diagnosis of MMA. Nineteen STR markers which are linked to the MUT, MMAA and MMAB genes (the genes with known causative mutations in MMA) were selected for PCR-amplification using two recently designed multiplex PCR panels. Next, the families that were diagnosed with homozygous haplotypes for the candidate genes were directly sequenced. Five novel mutations (c.805delG, c.693delC, c.223A > T, c.668A > G and c.976A > G in MUT) were identified beside other 4 recurrent mutations (c.361insT in MUT, c.571C > T and c.197-1 G > T in MMAB and c.1075C > T in MMAA). In silico analyses were also performed to predict the pathogenicity of the identified variants. The mutation c.571C > T in MMAB was the most common mutation in our study.
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Affiliation(s)
- Mehdi Shafaat
- Department of Genetics, Islamic Azad University, Tehran Medical Sciences Branch, Tehran, Iran
| | - Mohammad Reza Alaee
- Pediatric Endocrinology and Metabolism, Mofid Children's Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Rahmanifar
- Iranian National Society for Study of Inborn Metabolic Diseases, Tehran, Iran
| | - Aria Setoodeh
- Department of Pediatrics, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Razzaghy-Azar
- Metabolic Disorders Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Hazrat Aliasghar Childrens Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Hamideh Bagherian
- Medical Genetics Laboratory, Kawsar Human Genetics Research Center, No. 41 Majlesi St., Vali Asr St., Tehran, 1595645513, Iran
| | - Samira Dabbagh Bagheri
- Medical Genetics Laboratory, Kawsar Human Genetics Research Center, No. 41 Majlesi St., Vali Asr St., Tehran, 1595645513, Iran
| | - Fatemeh Zafarghandi Motlagh
- Medical Genetics Laboratory, Kawsar Human Genetics Research Center, No. 41 Majlesi St., Vali Asr St., Tehran, 1595645513, Iran
| | - Mehrdad Hashemi
- Department of Genetics, Islamic Azad University, Tehran Medical Sciences Branch, Tehran, Iran
| | - Maryam Abiri
- Medical Genetics Laboratory, Kawsar Human Genetics Research Center, No. 41 Majlesi St., Vali Asr St., Tehran, 1595645513, Iran.
- Department of Medical Genetics and Molecular Biology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
| | - Sirous Zeinali
- Medical Genetics Laboratory, Kawsar Human Genetics Research Center, No. 41 Majlesi St., Vali Asr St., Tehran, 1595645513, Iran.
- Department of Molecular Medicine, Biotechnology Research Center, Pasteur Institute of Iran, Pasteur St., Tehran, Iran.
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25
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Evans M, Truby H, Boneh A. The Relationship between Dietary Intake, Growth, and Body Composition in Inborn Errors of Intermediary Protein Metabolism. J Pediatr 2017. [PMID: 28629683 DOI: 10.1016/j.jpeds.2017.05.048] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To examine relationships between dietary intake, growth and body composition patterns in patients with inborn errors of intermediary protein metabolism and to determine a safe protein:energy ratio (P:E ratio) associated with optimal growth outcomes. STUDY DESIGN Retrospective longitudinal data of growth and dietary intake in patients (n = 75) with isovaleric acidemia (IVA; n = 7), methylmalonic acidemia/propionic acidemia (MMA/PA; n = 14), urea cycle defects (UCD; n = 44), classical maple syrup urine disease (MSUD; n = 10) were collected. Prospective longitudinal data of growth, dietary intake, and body composition from 21 patients: IVA (n = 5), MMA/PA (n = 6), UCD (n = 7), and MSUD (n = 3) were collected at clinic visits. RESULTS Fifty-two of 75 (66%), 49 of 74 (68%), and 44 of 65 (68%) patients had a z-score of 0 (±1) for lifetime weight, height, and body mass index, respectively. Patients with MMA/PA had the lowest median height and weight z-scores, and MSUD patients had highest median body mass index z-score at all ages. In IVA, MMA/PA, and UCD, total natural protein intake met or exceeded the Food and Agriculture Organization of the United Nations (FAO)/World Health Organization (WHO)/United Nations University (UNU) recommended safe levels. Median percentage fat mass was 17.6% in IVA, 20.7% in MMA/PA, 19.4% in UCD, and 17.8% in MSUD. There was a significant negative correlation between percentage fat mass and total protein intake in IVA, MMA/PA, and UCD (r = -0.737; P = .010). The correlation between the P:E ratio and growth variables in IVA, MMA/PA, and UCD suggest a safe P:E ratio (>1.5 to < 2.9) g protein:100 kcal/day. CONCLUSION Growth outcomes in inborn errors of intermediary protein metabolism are not always ideal. Most patients with IVA, MMA/PA, and UCD consume sufficient natural protein to meet FAO/WHO/UNU recommendations. A P:E ratio range of (>1.5 to < 2.9)g protein/100 kcal/day correlates with optimal growth outcomes.
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Affiliation(s)
- Maureen Evans
- Department of Metabolic Medicine, Royal Children's Hospital and Murdoch Children's Research Institute, Melbourne, Australia; Department of Nutrition and Food Services, Royal Children's Hospital, Melbourne, Australia; Department of Nutrition, Dietetics and Food, Monash University, Melbourne, Australia.
| | - Helen Truby
- Department of Nutrition, Dietetics and Food, Monash University, Melbourne, Australia
| | - Avihu Boneh
- Department of Metabolic Medicine, Royal Children's Hospital and Murdoch Children's Research Institute, Melbourne, Australia; Department of Nutrition, Dietetics and Food, Monash University, Melbourne, Australia; Department of Pediatrics, University of Melbourne, Melbourne, Australia
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26
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Goldstein A, Vockley J. Clinical trials examining treatments for inborn errors of amino acid metabolism. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2017.1275565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Amy Goldstein
- Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jerry Vockley
- Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Sakamoto R, Nakamura K, Kido J, Matsumoto S, Mitsubuchi H, Inomata Y, Endo F. Improvement in the prognosis and development of patients with methylmalonic acidemia after living donor liver transplant. Pediatr Transplant 2016; 20:1081-1086. [PMID: 27670840 DOI: 10.1111/petr.12804] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2016] [Indexed: 01/13/2023]
Abstract
Liver transplant is a treatment option for patients with MMA-emia. While this therapy does not bring about a complete cure, it is expected to prolong survival and improve the QOL of patients. The aim of this study was to evaluate the significance of LDLT for patients with MMA-emia in Japan. Clinical information on 13 patients with MMA-emia who underwent LDLT was acquired using a self-developed questionnaire sent to the doctors who provided medical care to patients with MMA-emia after LDLT. Almost all of the patients continued on a protein-restricted diet, and the number of acidosis attacks had significantly decreased. Physical growth had recovered to within the normal range by 2.5 years after LDLT, especially in patients who underwent LDLT before the age of 1 year. The average propionyl carnitine (C3) level had significantly decreased after LDLT, and the DQs had not worsened. Liver transplant should be performed for MMA-emia in early life. This can be expected to maintain neurological development and improve the growth and QOL of patients. However, LDLT is not a curative treatment for MMA-emia. A protein-restricted diet should be continued, and renal function should be monitored closely, with consideration of a renal transplant.
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Affiliation(s)
| | | | - Jun Kido
- Pediatrics, Kumamoto University, Kumamoto, Japan
| | | | | | - Yukihiro Inomata
- Transplantation and Pediatric Surgery, Kumamoto University, Kumamoto, Japan
| | - Fumio Endo
- Pediatrics, Kumamoto University, Kumamoto, Japan
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Finding Treatments for Genetic Metabolic Disease. CURRENT PEDIATRICS REPORTS 2016. [DOI: 10.1007/s40124-016-0113-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
PURPOSE OF REVIEW Recent clinical studies and management guidelines for the treatment of the organic acidopathies methylmalonic acidemia (MMA) and propionic acidemia address the scope of interventions to maximize health and quality of life. Unfortunately, these disorders continue to cause significant morbidity and mortality due to acute and chronic systemic and end-organ injury. RECENT FINDINGS Dietary management with medical foods has been a mainstay of therapy for decades, yet well controlled patients can manifest growth, development, cardiac, ophthalmological, renal, and neurological complications. Patients with organic acidopathies suffer metabolic brain injury that targets specific regions of the basal ganglia in a distinctive pattern, and these injuries may occur even with optimal management during metabolic stress. Liver transplantation has improved quality of life and metabolic stability, yet transplantation in this population does not entirely prevent brain injury or the development of optic neuropathy and cardiac disease. SUMMARY Management guidelines should identify necessary screening for patients with methylmalonic acidemia and propionic acidemia, and improve anticipatory management of progressive end-organ disease. Liver transplantation improves overall metabolic control, but injury to nonregenerative tissues may not be mitigated. Continued use of medical foods in these patients requires prospective studies to demonstrate evidence of benefit in a controlled manner.
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Abstract
The three essential branched-chain amino acids (BCAAs), leucine, isoleucine and valine, share the first enzymatic steps in their metabolic pathways, including a reversible transamination followed by an irreversible oxidative decarboxylation to coenzyme-A derivatives. The respective oxidative pathways subsequently diverge and at the final steps yield acetyl- and/or propionyl-CoA that enter the Krebs cycle. Many disorders in these pathways are diagnosed through expanded newborn screening by tandem mass spectrometry. Maple syrup urine disease (MSUD) is the only disorder of the group that is associated with elevated body fluid levels of the BCAAs. Due to the irreversible oxidative decarboxylation step distal enzymatic blocks in the pathways do not result in the accumulation of amino acids, but rather to CoA-activated small carboxylic acids identified by gas chromatography mass spectrometry analysis of urine and are therefore classified as organic acidurias. Disorders in these pathways can present with a neonatal onset severe-, or chronic intermittent- or progressive forms. Metabolic instability and increased morbidity and mortality are shared between inborn errors in the BCAA pathways, while treatment options remain limited, comprised mainly of dietary management and in some cases solid organ transplantation.
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Affiliation(s)
- I Manoli
- Organic Acid Research Section, Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, NIH, Bethesda, MD, USA
| | - C P Venditti
- Organic Acid Research Section, Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, NIH, Bethesda, MD, USA
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Caterino M, Chandler RJ, Sloan JL, Dorko K, Cusmano-Ozog K, Ingenito L, Strom SC, Imperlini E, Scolamiero E, Venditti CP, Ruoppolo M. The proteome of methylmalonic acidemia (MMA): the elucidation of altered pathways in patient livers. MOLECULAR BIOSYSTEMS 2016; 12:566-74. [PMID: 26672496 DOI: 10.1039/c5mb00736d] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Methylmalonic acidemia (MMA) is a heterogeneous and severe autosomal recessive inborn error of metabolism most commonly caused by the deficient activity of the vitamin B12 dependent enzyme, methylmalonyl-CoA mutase (MUT). The main treatment for MMA patients is the dietary restriction of propiogenic amino acids and carnitine supplementation. Despite treatment, the prognosis for vitamin B12 non-responsive patients remains poor and is associated with neonatal lethality, persistent morbidity and decreased life expectancy. While multi-organ pathology is a feature of MMA, the liver is severely impacted by mitochondrial dysfunction which likely underlies the metabolic instability experienced by the patients. Liver and/or combined liver/kidney transplantation is therefore sometimes performed in severely affected patients. Using liver specimens from donors and MMA patients undergoing elective liver transplantation collected under a dedicated natural history protocol (clinicaltrials.gov: NCT00078078), we employed proteomics to characterize the liver pathology and impaired hepatic metabolism observed in the patients. Pathway analysis revealed perturbations of enzymes involved in energy metabolism, gluconeogenesis and Krebs cycle anaplerosis. Our findings identify new pathophysiologic and therapeutic targets that could be valuable for designing alternative therapies to alleviate clinical manifestations seen in this disorder.
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Affiliation(s)
- Marianna Caterino
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università degli Studi di Napoli, "Federico II", Naples, Italy and CEINGE Biotecnologie Avanzate, Naples, Italy
| | - Randy J Chandler
- Organic Acid Research Section, Genetics and Molecular Biology Branch, National Human Genome Research Institute, National Institute of Health, Bethesda MD 2092, USA.
| | - Jennifer L Sloan
- Organic Acid Research Section, Genetics and Molecular Biology Branch, National Human Genome Research Institute, National Institute of Health, Bethesda MD 2092, USA.
| | - Kenneth Dorko
- Department of Pharmacology, Toxicology and Therapeutics, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Kristina Cusmano-Ozog
- Division Genetics and Metabolism, Children's National Medical Center, Washington DC, USA
| | | | - Stephen C Strom
- Department of Laboratory Medicine, Division of Pathology, Karolinska Institutet, Stockholm, Sweden
| | | | | | - Charles P Venditti
- Organic Acid Research Section, Genetics and Molecular Biology Branch, National Human Genome Research Institute, National Institute of Health, Bethesda MD 2092, USA.
| | - Margherita Ruoppolo
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università degli Studi di Napoli, "Federico II", Naples, Italy and CEINGE Biotecnologie Avanzate, Naples, Italy
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Colín-González A, Paz-Loyola A, Serratos I, Seminotti B, Ribeiro C, Leipnitz G, Souza D, Wajner M, Santamaría A. Toxic synergism between quinolinic acid and organic acids accumulating in glutaric acidemia type I and in disorders of propionate metabolism in rat brain synaptosomes: Relevance for metabolic acidemias. Neuroscience 2015; 308:64-74. [DOI: 10.1016/j.neuroscience.2015.09.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 08/29/2015] [Accepted: 09/01/2015] [Indexed: 12/11/2022]
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Daly A, Evans S, Gerrard A, Santra S, Vijay S, MacDonald A. The Nutritional Intake of Patients with Organic Acidaemias on Enteral Tube Feeding: Can We Do Better? JIMD Rep 2015; 28:29-39. [PMID: 26510853 PMCID: PMC5059221 DOI: 10.1007/8904_2015_443] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 04/01/2015] [Accepted: 04/13/2015] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Detailed nutritional intake data on children with organic acidaemias (OA) (propionic acidaemia (PA), vitamin B12 nonresponsive methylmalonic acidaemia (MMA) and isovaleric acidaemia (IVA)) remains unreported. Aim and subjects: A review of the longitudinal nutritional intake of 14 children with organic acidaemias (PA n = 8; MMA n = 5; IVA n = 1) dependent on enteral tube feeding (≥90% of energy requirements) from a single treatment centre. METHODS Nutritional intake (energy, protein, precursor-free L-amino acids, vitamins and minerals), anthropometry and nutritional biochemistry data were collated from diagnosis to current age. RESULTS The median energy intake was only 72% (63-137) of the estimated average DH (1991) requirement (EAR), decreasing significantly by 40% between 6 months and 5 years (p < 0.05). Total protein intake met WHO/FAO/UNU (2007) safe intake levels with median (range) precursor-free L-amino acids providing 21% (14-28) of total protein intake. Median mineral intake for sodium was 57% (20-97%), potassium 64% (27-125%) and magnesium 72% (22-116%) and was consistently < RNI for all age points. Fibre median intake was 4 g/day (0-11 g), and fluid intake provided 80% (60-100%) of the requirements for age. Linear growth was poor, and children were overweight for their height (1-10 years: z score median weight +0.6, height -1.2). Nutritional markers consistently indicated that plasma valine concentrations were < target reference ranges in PA and MMA. Iron deficiency anaemia was common in MMA/PA, and in PA, 50% of plasma zinc concentrations were < reference range. CONCLUSION In MMA/PA, energy intake decreases over time, weight gain accelerates, but linear height is poor. There are many nutrient deficiencies which may affect short- and long-term outcome of patients with organic acidaemias. The quality of long-term diet in these conditions deserves more attention.
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Affiliation(s)
- Anne Daly
- Departments of Dietetics and Inherited Metabolic Disorders, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK.
| | - S Evans
- Departments of Dietetics and Inherited Metabolic Disorders, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - A Gerrard
- Departments of Dietetics and Inherited Metabolic Disorders, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - S Santra
- Departments of Dietetics and Inherited Metabolic Disorders, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - S Vijay
- Departments of Dietetics and Inherited Metabolic Disorders, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - A MacDonald
- Departments of Dietetics and Inherited Metabolic Disorders, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
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Campo K, Castro G, Hamilton V, Cabello JF, Raimann E, Arias C, Cornejo V. Energy Expenditure in Chilean Children with Maple Syrup Urine Disease (MSUD). JIMD Rep 2015; 26:69-76. [PMID: 26458887 DOI: 10.1007/8904_2015_500] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 09/14/2015] [Accepted: 09/16/2015] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Maple syrup urine disease (MSUD) is an autosomal recessive disorder caused by a blockage of branched-chain keto acid of BCAA (branched-chain keto acid dehydrogenase, BCKDH) leading to neurological damage induced by accumulation of leucine and metabolites. MSUD expenditure and energy requirement information is limited. OBJECTIVE To determine if basal/total energy expenditure (BEE/TEE) is comparable between different determination methods and if values agree with recommendations of energy in MSUD children, and whether they relate to nutritional status. METHODS Case-control study between MSUD (n = 16) and healthy children (n = 11) aged 6-18 years. Current nutritional status, physical activity level, body composition by DEXA and BEE/TEE by indirect calorimetry (BEEr) and predictive equations (FAO/WHO/ONU - WHO - and Schofield) were assessed; STATA 2013 (p < 0.05). RESULTS When comparing the energy expenditure variables, there was no significant difference between groups. Moreover, compared to BEEr, equations underestimate according to BEE WHO and Schofield, respectively (P = 0.00; 0.02). The WHO equation had lower average calorie difference, greater concordance correlation and association with indirect calorimetry compared to the Schofield equation for both groups, being the best predictor of the BEE for MSUD group. CONCLUSION Energy recommendations for MSUD children are according to energy expenditure; thus the use of WHO equation is a clinically and statistically feasible tool for its determination.
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Affiliation(s)
- Karen Campo
- INTA - Instituto de Nutrición y TecnologÚa de Alimentos Doctor Fernando Monckeberg Barro, University of Chile, Av. El Líbano 5524, Macul, Macul, Santiago, Chile.
| | - Gabriela Castro
- INTA - Instituto de Nutrición y TecnologÚa de Alimentos Doctor Fernando Monckeberg Barro, University of Chile, Av. El Líbano 5524, Macul, Macul, Santiago, Chile
| | - Valerie Hamilton
- INTA - Instituto de Nutrición y TecnologÚa de Alimentos Doctor Fernando Monckeberg Barro, University of Chile, Av. El Líbano 5524, Macul, Macul, Santiago, Chile
| | - Juan Francisco Cabello
- INTA - Instituto de Nutrición y TecnologÚa de Alimentos Doctor Fernando Monckeberg Barro, University of Chile, Av. El Líbano 5524, Macul, Macul, Santiago, Chile
| | - Erna Raimann
- INTA - Instituto de Nutrición y TecnologÚa de Alimentos Doctor Fernando Monckeberg Barro, University of Chile, Av. El Líbano 5524, Macul, Macul, Santiago, Chile
| | - Carolina Arias
- INTA - Instituto de Nutrición y TecnologÚa de Alimentos Doctor Fernando Monckeberg Barro, University of Chile, Av. El Líbano 5524, Macul, Macul, Santiago, Chile
| | - Verónica Cornejo
- INTA - Instituto de Nutrición y TecnologÚa de Alimentos Doctor Fernando Monckeberg Barro, University of Chile, Av. El Líbano 5524, Macul, Macul, Santiago, Chile
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Colín-González AL, Paz-Loyola AL, Serratos IN, Seminotti B, Ribeiro CAJ, Leipnitz G, Souza DO, Wajner M, Santamaría A. The effect of WIN 55,212-2 suggests a cannabinoid-sensitive component in the early toxicity induced by organic acids accumulating in glutaric acidemia type I and in related disorders of propionate metabolism in rat brain synaptosomes. Neuroscience 2015; 310:578-88. [PMID: 26431622 DOI: 10.1016/j.neuroscience.2015.09.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 09/03/2015] [Accepted: 09/18/2015] [Indexed: 10/23/2022]
Abstract
Several physiological processes in the CNS are regulated by the endocannabinoid system (ECS). Cannabinoid receptors (CBr) and CBr agonists have been involved in the modulation of the N-methyl-D-aspartate receptor (NMDAr) activation. Glutaric (GA), 3-hydroxyglutaric (3-OHGA), methylmalonic (MMA) and propionic (PA) acids are endogenous metabolites produced and accumulated in the brain of children affected by severe organic acidemias (OAs) with neurodegeneration. Oxidative stress and excitotoxicity have been involved in the toxic pattern exerted by these organic acids. Studying the early pattern of toxicity exerted by these metabolites is crucial to explain the extent of damage that they can produce in the brain. Herein, we investigated the effects of the synthetic CBr agonist WIN 55,212-2 (WIN) on early markers of GA-, 3-OHGA-, MMA- and PA-induced toxicity in brain synaptosomes from adult (90-day-old) and adolescent (30-day-old) rats. As pre-treatment, WIN exerted protective effects on the GA- and MMA-induced mitochondrial dysfunction, and prevented the reactive oxygen species (ROS) formation and lipid peroxidation induced by all metabolites. Our findings support a protective and modulatory role of cannabinoids in the early toxic events elicited by toxic metabolites involved in OAs.
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Affiliation(s)
- A L Colín-González
- Laboratorio de Aminoácidos Excitadores, Instituto Nacional de Neurología y Neurocirugía, S.S.A., Mexico City, Mexico
| | - A L Paz-Loyola
- Laboratorio de Aminoácidos Excitadores, Instituto Nacional de Neurología y Neurocirugía, S.S.A., Mexico City, Mexico
| | - I N Serratos
- Laboratorio de Aminoácidos Excitadores, Instituto Nacional de Neurología y Neurocirugía, S.S.A., Mexico City, Mexico; Departamento de Química, Universidad Autónoma Metropolitana-Iztapalapa, Mexico
| | - B Seminotti
- Departamento de Bioquímica, Instituto de Ciências Básicas da Sáude, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - C A J Ribeiro
- Departamento de Bioquímica, Instituto de Ciências Básicas da Sáude, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - G Leipnitz
- Departamento de Bioquímica, Instituto de Ciências Básicas da Sáude, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - D O Souza
- Departamento de Bioquímica, Instituto de Ciências Básicas da Sáude, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - M Wajner
- Departamento de Bioquímica, Instituto de Ciências Básicas da Sáude, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil; Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil.
| | - A Santamaría
- Laboratorio de Aminoácidos Excitadores, Instituto Nacional de Neurología y Neurocirugía, S.S.A., Mexico City, Mexico.
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Manoli I, Myles JG, Sloan JL, Shchelochkov OA, Venditti CP. A critical reappraisal of dietary practices in methylmalonic acidemia raises concerns about the safety of medical foods. Part 1: isolated methylmalonic acidemias. Genet Med 2015; 18:386-95. [PMID: 26270765 PMCID: PMC4752925 DOI: 10.1038/gim.2015.102] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 06/16/2015] [Indexed: 12/04/2022] Open
Abstract
PURPOSE Medical foods for methylmalonic and propionic acidemias (MMA/PA) contain minimal valine, isoleucine, methionine and threonine, but have been formulated with increased leucine. We aimed to assess the effects of imbalanced branched-chain amino acid intake on metabolic and growth parameters in a cohort of MMA patients ascertained via a natural history study. METHODS Cross-sectional anthropometric and body composition measurements were correlated with diet content and disease-related biomarkers in 61 patients with isolated MMA (46 mut, 9 cblA and 6 cblB). RESULTS Patients with MMA tolerated close to the recommended daily allowance (RDA) of complete protein (mut0: 99.45 ± 32.05% RDA). However, 85% received medical foods, the protein-equivalent in which often exceeded complete protein intake (35%). Medical food consumption resulted in low plasma valine and isoleucine concentrations, prompting paradoxical supplementation with these propiogenic amino acids. Weight and height–for age Z-scores correlated negatively with the leucine/valine intake ratio (r=−0.453, P=0.014, R2=0.209 and r=−0.341, P=0.05, R2=0.123, respectively). CONCLUSION Increased leucine intake in patients with MMA resulted in iatrogenic amino acid deficiencies and was associated with adverse growth outcomes. Medical foods for propionate oxidation disorders need to be redesigned and studied prospectively, to ensure efficacy and safety. TRIAL REGISTRATION This clinical study is registered in www.clinicaltrials.gov with the ID: NCT00078078. Study URL: http://clinicaltrials.gov/ct2/show/NCT00078078
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Affiliation(s)
- Irini Manoli
- Organic Acid Research Section, Genetics and Molecular Biology Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Jennifer G Myles
- Nutrition Department, National Institutes of Health, Bethesda, Maryland, USA
| | - Jennifer L Sloan
- Organic Acid Research Section, Genetics and Molecular Biology Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Oleg A Shchelochkov
- Division of Genetics, Stead Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Charles P Venditti
- Organic Acid Research Section, Genetics and Molecular Biology Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
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Boyer SW, Barclay LJ, Burrage LC. Inherited Metabolic Disorders: Aspects of Chronic Nutrition Management. Nutr Clin Pract 2015; 30:502-10. [PMID: 26079521 PMCID: PMC4515158 DOI: 10.1177/0884533615586201] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
The introduction of newborn screening and the development of new therapies have led to an expanding population of patients with inherited metabolic disorders, and these patients are now entering adulthood. Dietary therapy is the mainstay of treatment for many of these disorders, and thus, trained metabolic dietitians are critical members of the multidisciplinary team required for management of such patients. The main goals of dietary therapy in inborn errors of metabolism are the maintenance of normal growth and development while limiting offending metabolites and providing deficient products. Typically, the offending metabolite is either significantly reduced or removed completely from the diet and then reintroduced in small quantities until blood levels are within the normal range. Such treatment is required in infancy, childhood, and adulthood and requires careful monitoring of micronutrient and macronutrient intake throughout the life span. The goal of this review is to highlight the basic principles of chronic nutrition management of the inborn errors of protein, carbohydrate, and fat metabolism.
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Affiliation(s)
- Suzanne W Boyer
- Department of Molecular and Human Genetics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Lisa J Barclay
- Department of Food and Nutrition, Texas Children's Hospital, Houston, Texas
| | - Lindsay C Burrage
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
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Ktena YP, Paul SM, Hauser NS, Sloan JL, Gropman A, Manoli I, Venditti CP. Delineating the spectrum of impairments, disabilities, and rehabilitation needs in methylmalonic acidemia (MMA). Am J Med Genet A 2015; 167A:2075-84. [PMID: 25959030 DOI: 10.1002/ajmg.a.37127] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Accepted: 04/02/2015] [Indexed: 11/08/2022]
Abstract
Methylmalonic acidemia patients have complex rehabilitation needs that can be targeted to optimize societal independence and quality of life. Thirty-seven individuals with isolated MMA (28 mut, 5 cblA, 4 cblB), aged 2-33 years, were enrolled in a natural history study, and underwent age-appropriate clinical assessments to characterize impairments and disabilities. Neurological examination and brain imaging studies were used to document movement disorders and the presence of basal ganglia injury. A range of impairments and disabilities were identified by a team of physical medicine experts. Movement disorders, such as chorea and tremor, were common (n = 31, 83%), even among patients without evidence of basal ganglia injury. Joint hypermobility (n = 24, 69%) and pes planus (n = 22, 60%) were frequent and, in many cases, under-recognized. 23 (62%) patients required gastrostomy feedings. 18/31 patients >4 years old (58%) had difficulties with bathing and dressing. 16 of 23 school-aged patients received various forms of educational support. Five of the 10 adult patients were employed or in college; three lived independently. Unmet needs were identified in access to rehabilitation services, such as physical therapy (unavailable to 14/31), and orthotics (unavailable to 15/22). We conclude that patients with MMA are challenged by a number of functional limitations in essential activities of mobility, self-care, and learning, in great part caused by movement disorders and ligamentous laxity. Early assessment, referral, and implementation of age-appropriate rehabilitation services should significantly improve independence and quality of life.
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Affiliation(s)
- Yiouli P Ktena
- Organic Acid Research Section, Genetics and Molecular Biology Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Scott M Paul
- Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Natalie S Hauser
- Organic Acid Research Section, Genetics and Molecular Biology Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Jennifer L Sloan
- Organic Acid Research Section, Genetics and Molecular Biology Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Andrea Gropman
- Center for Neuroscience Research (CNR), Children's National Medical Center, Washington, District of Columbia
| | - Irini Manoli
- Organic Acid Research Section, Genetics and Molecular Biology Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Charles P Venditti
- Organic Acid Research Section, Genetics and Molecular Biology Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
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Yilmaz LS, Walhout AJM. Worms, bacteria, and micronutrients: an elegant model of our diet. Trends Genet 2014; 30:496-503. [PMID: 25172020 PMCID: PMC4399232 DOI: 10.1016/j.tig.2014.07.010] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 07/22/2014] [Accepted: 07/22/2014] [Indexed: 01/21/2023]
Abstract
Micronutrients are required in small proportions in a diet to carry out key metabolic roles for biomass and energy production. Humans receive micronutrients either directly from their diet or from gut microbiota that metabolize other nutrients. The nematode Caenorhabditis elegans and its bacterial diet provide a relatively simple and genetically tractable model to study both direct and microbe-mediated effects of micronutrients. Recently, this model has been used to gain insight into the relationship between micronutrients, physiology, and metabolism. In particular, two B-type vitamins, vitamin B12 and folate, have been studied in detail. Here we review how C. elegans and its bacterial diet provide a powerful interspecies systems biology model that facilitates the precise delineation of micronutrient effects and the mechanisms involved.
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Affiliation(s)
- Lutfu Safak Yilmaz
- Program in Systems Biology, Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Albertha J M Walhout
- Program in Systems Biology, Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, MA, USA.
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40
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Baker EH, Sloan JL, Hauser NS, Gropman AL, Adams DR, Toro C, Manoli I, Venditti CP. MRI characteristics of globus pallidus infarcts in isolated methylmalonic acidemia. AJNR Am J Neuroradiol 2014; 36:194-201. [PMID: 25190203 DOI: 10.3174/ajnr.a4087] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Bilateral infarcts confined to the globus pallidus are unusual and occur in conjunction with only a few disorders, including isolated methylmalonic acidemia, a heterogeneous inborn error of metabolism. On the basis of neuroradiographic features of metabolic strokes observed in a large cohort of patients with methylmalonic acidemia, we have devised a staging system for methylmalonic acidemia-related globus pallidus infarcts. MATERIALS AND METHODS Forty patients with isolated methylmalonic acidemia and neurologic symptoms underwent clinical brain MR imaging studies, which included 3D-T1WI. Infarcted globus pallidus segments were neuroanatomically characterized, and infarct volumes were measured. RESULTS Globus pallidus infarcts were present in 19 patients; all were bilateral, and most were left-dominant. A neuroanatomic scoring system based on the infarct patterns was devised; this revealed a 5-stage hierarchical susceptibility to metabolic infarct, with the posterior portion of the globus pallidus externa being the most vulnerable. Globus pallidus infarct prevalence by methylmalonic acidemia class was the following: cblA (5/7, 71%), cblB (3/7, 43%), mut(o) (10/22, 45%), and mut- (1/4, 25%). Tiny lacunar infarcts in the pars reticulata of the substantia nigra, previously unrecognized in methylmalonic acidemia, were found in 17 patients, 13 of whom also had a globus pallidus infarct. CONCLUSIONS The staged pattern of globus pallidus infarcts in isolated methylmalonic acidemia suggests a nonuniform, regionally specific cellular susceptibility to metabolic injury, even for patients having milder biochemical phenotypes. In support of this hypothesis, the delineation of lacunar infarcts in the pars reticulata of the substantia nigra, a tissue functionally and histologically identical to the globus pallidus interna, supports the concept of cell-specific pathology.
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Affiliation(s)
- E H Baker
- From the Department of Radiology and Imaging Sciences (E.H.B.), Clinical Center
| | - J L Sloan
- Genetics and Molecular Biology Branch (J.L.S., I.M., C.P.V.)
| | - N S Hauser
- Medical Genetics and Metabolism Department (N.S.H.), Children's Hospital Central California, Madera, California
| | - A L Gropman
- Department of Neurology (A.L.G.), Children's National Medical Center, Washington, DC
| | | | - C Toro
- Undiagnosed Diseases Program (C.T.), National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - I Manoli
- Genetics and Molecular Biology Branch (J.L.S., I.M., C.P.V.)
| | - C P Venditti
- Genetics and Molecular Biology Branch (J.L.S., I.M., C.P.V.)
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41
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Baumgartner MR, Hörster F, Dionisi-Vici C, Haliloglu G, Karall D, Chapman KA, Huemer M, Hochuli M, Assoun M, Ballhausen D, Burlina A, Fowler B, Grünert SC, Grünewald S, Honzik T, Merinero B, Pérez-Cerdá C, Scholl-Bürgi S, Skovby F, Wijburg F, MacDonald A, Martinelli D, Sass JO, Valayannopoulos V, Chakrapani A. Proposed guidelines for the diagnosis and management of methylmalonic and propionic acidemia. Orphanet J Rare Dis 2014; 9:130. [PMID: 25205257 PMCID: PMC4180313 DOI: 10.1186/s13023-014-0130-8] [Citation(s) in RCA: 416] [Impact Index Per Article: 41.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 08/05/2014] [Indexed: 12/15/2022] Open
Abstract
Methylmalonic and propionic acidemia (MMA/PA) are inborn errors of metabolism characterized by accumulation of propionic acid and/or methylmalonic acid due to deficiency of methylmalonyl-CoA mutase (MUT) or propionyl-CoA carboxylase (PCC). MMA has an estimated incidence of ~ 1: 50,000 and PA of ~ 1:100’000 -150,000. Patients present either shortly after birth with acute deterioration, metabolic acidosis and hyperammonemia or later at any age with a more heterogeneous clinical picture, leading to early death or to severe neurological handicap in many survivors. Mental outcome tends to be worse in PA and late complications include chronic kidney disease almost exclusively in MMA and cardiomyopathy mainly in PA. Except for vitamin B12 responsive forms of MMA the outcome remains poor despite the existence of apparently effective therapy with a low protein diet and carnitine. This may be related to under recognition and delayed diagnosis due to nonspecific clinical presentation and insufficient awareness of health care professionals because of disease rarity. These guidelines aim to provide a trans-European consensus to guide practitioners, set standards of care and to help to raise awareness. To achieve these goals, the guidelines were developed using the SIGN methodology by having professionals on MMA/PA across twelve European countries and the U.S. gather all the existing evidence, score it according to the SIGN evidence level system and make a series of conclusive statements supported by an associated level of evidence. Although the degree of evidence rarely exceeds level C (evidence from non-analytical studies like case reports and series), the guideline should provide a firm and critical basis to guide practice on both acute and chronic presentations, and to address diagnosis, management, monitoring, outcomes, and psychosocial and ethical issues. Furthermore, these guidelines highlight gaps in knowledge that must be filled by future research. We consider that these guidelines will help to harmonize practice, set common standards and spread good practices, with a positive impact on the outcomes of MMA/PA patients.
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42
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Humphrey M, Truby H, Boneh A. New ways of defining protein and energy relationships in inborn errors of metabolism. Mol Genet Metab 2014; 112:247-58. [PMID: 24916709 DOI: 10.1016/j.ymgme.2014.05.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 05/14/2014] [Indexed: 12/30/2022]
Abstract
Dietary restrictions required to manage individuals with inborn errors of metabolism (IEM) are essential for metabolic control, however may result in an increased risk to both short and long-term nutritional status. Dietary factors most likely to influence nutritional status include energy intake, protein quality and quantity, micronutrient intake and the frequency and extent to which the diet must be altered during periods of increased physical or metabolic stress. Patients on the most restrictive diets, including those with intakes consisting of low levels of natural protein or those with recurrent illness or frequent metabolic decompensation carry the most nutritional risk. Due to the difficulties in determining condition specific requirements, dietary intake recommendations and nutritional monitoring tools used in patients with IEM are the same as, or extrapolated from, those used in healthy populations. As a consequence, evidence is lacking for the safest dietary prescriptions required to manage these patients long term, as tolerance to dietary therapy is generally described in terms of metabolic stability rather than long term nutritional and health outcomes. As the most frequent therapeutic dietary manipulation in IEM is alteration in dietary protein, and as protein status is critically dependent on adequate energy provision, the use of a Protein to Energy ratio (P:E ratio) as an additional tool will better define the relationship between these critical components. This could accurately define dietary quality and ensure that not only an adequate, but also a safe and balanced intake is provided.
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Affiliation(s)
- Maureen Humphrey
- Metabolic Genetics, Victorian Clinical Genetic Services, Murdoch Children's Research Institute, The Royal Children's Hospital, Flemington Road, Parkville, Victoria, Melbourne 3052, Australia; Department of Nutrition and Food Services, Royal Children's Hospital, Flemington Road, Parkville, Victoria, Melbourne 3052, Australia; Be Active Sleep Eat (BASE) Facility, Department of Nutrition and Dietetics, Monash University, Faculty of Medicine, Nursing and Health Sciences, Level 1, 264 Ferntree Gully Road, VIC 3168, Melbourne, Australia.
| | - Helen Truby
- Be Active Sleep Eat (BASE) Facility, Department of Nutrition and Dietetics, Monash University, Faculty of Medicine, Nursing and Health Sciences, Level 1, 264 Ferntree Gully Road, VIC 3168, Melbourne, Australia.
| | - Avihu Boneh
- Metabolic Genetics, Victorian Clinical Genetic Services, Murdoch Children's Research Institute, The Royal Children's Hospital, Flemington Road, Parkville, Victoria, Melbourne 3052, Australia; Be Active Sleep Eat (BASE) Facility, Department of Nutrition and Dietetics, Monash University, Faculty of Medicine, Nursing and Health Sciences, Level 1, 264 Ferntree Gully Road, VIC 3168, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Royal Children's Hospital, Flemington Road, Parkville, Victoria, Melbourne 3052, Australia.
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43
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van Vliet D, Derks TGJ, van Rijn M, de Groot MJ, MacDonald A, Heiner-Fokkema MR, van Spronsen FJ. Single amino acid supplementation in aminoacidopathies: a systematic review. Orphanet J Rare Dis 2014; 9:7. [PMID: 24422943 PMCID: PMC3895659 DOI: 10.1186/1750-1172-9-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 12/27/2013] [Indexed: 12/15/2022] Open
Abstract
Aminoacidopathies are a group of rare and diverse disorders, caused by the deficiency of an enzyme or transporter involved in amino acid metabolism. For most aminoacidopathies, dietary management is the mainstay of treatment. Such treatment includes severe natural protein restriction, combined with protein substitution with all amino acids except the amino acids prior to the metabolic block and enriched with the amino acid that has become essential by the enzymatic defect. For some aminoacidopathies, supplementation of one or two amino acids, that have not become essential by the enzymatic defect, has been suggested. This so-called single amino acid supplementation can serve different treatment objectives, but evidence is limited. The aim of the present article is to provide a systematic review on the reasons for applications of single amino acid supplementation in aminoacidopathies treated with natural protein restriction and synthetic amino acid mixtures.
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Affiliation(s)
| | | | | | | | | | | | - Francjan J van Spronsen
- Department of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
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44
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Targeting proximal tubule mitochondrial dysfunction attenuates the renal disease of methylmalonic acidemia. Proc Natl Acad Sci U S A 2013; 110:13552-7. [PMID: 23898205 DOI: 10.1073/pnas.1302764110] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Isolated methylmalonic acidemia (MMA), caused by deficiency of the mitochondrial enzyme methylmalonyl-CoA mutase (MUT), is often complicated by end stage renal disease that is resistant to conventional therapies, including liver transplantation. To establish a viable model of MMA renal disease, Mut was expressed in the liver of Mut(-/-) mice as a stable transgene under the control of an albumin (INS-Alb-Mut) promoter. Mut(-/-);Tg(INS-Alb-Mut) mice, although completely rescued from neonatal lethality that was displayed by Mut(-/-) mice, manifested a decreased glomerular filtration rate (GFR), chronic tubulointerstitial nephritis and ultrastructural changes in the proximal tubule mitochondria associated with aberrant tubular function, as demonstrated by single-nephron GFR studies. Microarray analysis of Mut(-/-);Tg(INS-Alb-Mut) kidneys identified numerous biomarkers, including lipocalin-2, which was then used to monitor the response of the GFR to antioxidant therapy in the mouse model. Renal biopsies and biomarker analysis from a large and diverse patient cohort (ClinicalTrials.gov identifier: NCT00078078) precisely replicated the findings in the animals, establishing Mut(-/-);Tg(INS-Alb-Mut) mice as a unique model of MMA renal disease. Our studies suggest proximal tubular mitochondrial dysfunction is a key pathogenic mechanism of MMA-associated kidney disease, identify lipocalin-2 as a biomarker of increased oxidative stress in the renal tubule, and demonstrate that antioxidants can attenuate the renal disease of MMA.
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45
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Kruszka PS, Manoli I, Sloan JL, Kopp JB, Venditti CP. Renal growth in isolated methylmalonic acidemia. Genet Med 2013; 15:990-6. [PMID: 23639900 PMCID: PMC4149057 DOI: 10.1038/gim.2013.42] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 02/28/2013] [Indexed: 01/05/2023] Open
Abstract
PURPOSE We sought to predict renal growth based on clinical and metabolic parameters in patients with isolated methylmalonic acidemia, a group of disorders associated with chronic kidney disease. METHODS Fifty patients with methylmalonic acidemia, followed from 2004 to 2011, were classified by molecular genetics and studied using a combined cross-sectional and longitudinal design that included renal ultrasound examinations, anthropometric measurements, and metabolic phenotyping. Renal length was compared with that of healthy controls and modeled to other clinical parameters using multiple-regression analyses. RESULTS Comparisons with age-matched controls showed that renal length in subjects with methylmalonic acidemia was significantly decreased (P < 0.05). Stepwise regression modeling found that combinations of height, serum cystatin C, and serum methymalonic acid concentrations best predicted kidney size. The regression equations used to generate methylmalonic acidemia kidney nomograms were renal length (cm) = 6.79 + 0.22 × age for the controls and 6.80 + 0.09 × age for the methylmalonic acidemia cohort (P < 0.001; constant and slope). CONCLUSION Renal length, reflective of kidney growth, significantly decreased in patients with methylmalonic acidemia over time as compared with controls and was predictable with select clinical parameters. Cystatin C and serum methylmalonic acid concentrations were highly correlated with smaller kidneys and decreased renal function in this patient population.
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Affiliation(s)
- Paul S Kruszka
- Genetics and Molecular Biology Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
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