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Bleeker JC, Visser G, Clarke K, Ferdinandusse S, de Haan FH, Houtkooper RH, IJlst L, Kok IL, Langeveld M, van der Pol WL, de Sain‐van der Velden MGM, Sibeijn‐Kuiper A, Takken T, Wanders RJA, van Weeghel M, Wijburg FA, van der Woude LH, Wüst RCI, Cox PJ, Jeneson JAL. Nutritional ketosis improves exercise metabolism in patients with very long-chain acyl-CoA dehydrogenase deficiency. J Inherit Metab Dis 2020; 43:787-799. [PMID: 31955429 PMCID: PMC7384182 DOI: 10.1002/jimd.12217] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/23/2019] [Accepted: 01/14/2020] [Indexed: 12/11/2022]
Abstract
A maladaptive shift from fat to carbohydrate (CHO) oxidation during exercise is thought to underlie myopathy and exercise-induced rhabdomyolysis in patients with fatty acid oxidation (FAO) disorders. We hypothesised that ingestion of a ketone ester (KE) drink prior to exercise could serve as an alternative oxidative substrate supply to boost muscular ATP homeostasis. To establish a rational basis for therapeutic use of KE supplementation in FAO, we tested this hypothesis in patients deficient in Very Long-Chain acyl-CoA Dehydrogenase (VLCAD). Five patients (range 17-45 y; 4 M/1F) patients were included in an investigator-initiated, randomised, blinded, placebo-controlled, 2-way cross-over study. Patients drank either a KE + CHO mix or an isocaloric CHO equivalent and performed 35 minutes upright cycling followed by 10 minutes supine cycling inside a Magnetic Resonance scanner at individual maximal FAO work rate (fatmax; approximately 40% VO2 max). The protocol was repeated after a 1-week interval with the alternate drink. Primary outcome measures were quadriceps phosphocreatine (PCr), Pi and pH dynamics during exercise and recovery assayed by in vivo 31 P-MR spectroscopy. Secondary outcomes included plasma and muscle metabolites and respiratory gas exchange recordings. Ingestion of KE rapidly induced mild ketosis and increased muscle BHB content. During exercise at FATMAX, VLCADD-specific plasma acylcarnitine levels, quadriceps glycolytic intermediate levels and in vivo Pi/PCr ratio were all lower in KE + CHO than CHO. These results provide a rational basis for future clinical trials of synthetic ketone ester supplementation therapy in patients with FAO disorders. Trial registration: ClinicalTrials.gov. Protocol ID: NCT03531554; METC2014.492; ABR51222.042.14.
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Affiliation(s)
- Jeannette C. Bleeker
- Department of Metabolic Diseases, Wilhelmina Children's HospitalUniversity Medical Center UtrechtUtrechtThe Netherlands
- Department of Metabolic Diseases, Emma Children's Hospital, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Gepke Visser
- Department of Metabolic Diseases, Wilhelmina Children's HospitalUniversity Medical Center UtrechtUtrechtThe Netherlands
- Department of Metabolic Diseases, Emma Children's Hospital, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Kieran Clarke
- Department of Physiology, Anatomy and GeneticsUniversity of OxfordOxfordUK
| | - Sacha Ferdinandusse
- Laboratory Genetic Metabolic Diseases, Amsterdam Gastroenterology and Metabolism, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Ferdinand H. de Haan
- ACHIEVE, Center for Applied Research, Faculty of HealthUniversity of Applied Sciences AmsterdamAmsterdamThe Netherlands
| | - Riekelt H. Houtkooper
- Laboratory Genetic Metabolic Diseases, Amsterdam Gastroenterology and Metabolism, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Lodewijk IJlst
- Laboratory Genetic Metabolic Diseases, Amsterdam Gastroenterology and Metabolism, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Irene L. Kok
- Department of Metabolic Diseases, Wilhelmina Children's HospitalUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Mirjam Langeveld
- Department of Endocrinology and Metabolism, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - W. Ludo van der Pol
- Department of Neurology and Neurosurgery, Rudolf Magnus Institute of Neuroscience, Spieren voor Spieren KindercentrumUniversity Medical Center UtrechtUtrechtThe Netherlands
| | | | - Anita Sibeijn‐Kuiper
- Neuroimaging Center, Department of Biomedical Sciences of Cells and SystemsUniversity Medical Center GroningenGroningenThe Netherlands
| | - Tim Takken
- Center for Child Development & Exercise, Department of Medical PhysiologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Ronald J. A. Wanders
- Department of Metabolic Diseases, Emma Children's Hospital, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
- Laboratory Genetic Metabolic Diseases, Amsterdam Gastroenterology and Metabolism, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Michel van Weeghel
- Laboratory Genetic Metabolic Diseases, Amsterdam Gastroenterology and Metabolism, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
- Laboratory Genetic Metabolic Diseases, Amsterdam UMCUniversity of Amsterdam, Amsterdam Cardiovascular SciencesAmsterdamThe Netherlands
- Core Facility Metabolomics, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Frits A. Wijburg
- Department of Metabolic Diseases, Emma Children's Hospital, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Luc H. van der Woude
- Human Movement SciencesUniversity Medical Center GroningenGroningenThe Netherlands
| | - Rob C. I. Wüst
- Laboratory Genetic Metabolic Diseases, Amsterdam Gastroenterology and Metabolism, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Pete J. Cox
- Department of Physiology, Anatomy and GeneticsUniversity of OxfordOxfordUK
| | - Jeroen A. L. Jeneson
- Neuroimaging Center, Department of Biomedical Sciences of Cells and SystemsUniversity Medical Center GroningenGroningenThe Netherlands
- Center for Child Development & Exercise, Department of Medical PhysiologyUniversity Medical Center UtrechtUtrechtThe Netherlands
- Department of Radiology, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
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