The effects of transitioning from immediate release to extended release cysteamine therapy in Norwegian patients with nephropathic cystinosis: a retrospective study

BACKGROUND

Nephropathic cystinosis is a rare lysosomal storage disorder in which accumulation of cystine and formation of crystals particularly impair kidney function and gradually lead to multi-organ dysfunction. Lifelong therapy with the aminothiol cysteamine can delay the development of kidney failure and the need for transplant. The purpose of our long-term study was to explore the effects of transitioning from immediate release (IR) to extended release (ER) formulation in Norwegian patients in routine clinical care.

METHODS

We retrospectively analysed data on efficacy and safety in 10 paediatric and adult patients. Data were obtained from up to 6 years before and 6 years after transitioning from IR- to ER-cysteamine.

RESULTS

Mean white blood cell (WBC) cystine levels remained comparable between the different treatment periods (1.19 versus 1.38 nmol hemicystine/mg protein) although most patients under ER-cysteamine underwent dose reductions. For the non-transplanted patients, the mean estimated glomerular filtration rate (eGFR) change/year was more pronounced during ER-treatment (- 3.39 versus - 6.80 ml/min/1.73 m2/year) possibly influenced by individual events, such as tubulointerstitial nephritis and colitis. Growth measured by Z-height score tended to develop positively. Four of seven patients reported improvement of halitosis, one reported unchanged and two reported worsened symptoms. Most adverse drug reactions (ADRs) were of mild severity. One patient developed two serious ADRs and switched back to IR-formulation.

CONCLUSIONS

The results from this long-term retrospective study indicate that switching from IR- to ER-cysteamine was feasible and well tolerated under routine clinical practice. ER-cysteamine allowed satisfactory disease control over the long period considered. A higher resolution version of the Graphical abstract is available as Supplementary information.

Performance of Expanded Newborn Screening in Norway Supported by Post-Analytical Bioinformatics Tools and Rapid Second-Tier DNA Analyses

In 2012, the Norwegian newborn screening program (NBS) was expanded (eNBS) from screening for two diseases to that for 23 diseases (20 inborn errors of metabolism, IEMs) and again in 2018, to include a total of 25 conditions (21 IEMs). Between 1 March 2012 and 29 February 2020, 461,369 newborns were screened for 20 IEMs in addition to phenylketonuria (PKU). Excluding PKU, there were 75 true-positive (TP) (1:6151) and 107 (1:4311) false-positive IEM cases. Twenty-one percent of the TP cases were symptomatic at the time of the NBS results, but in two-thirds, the screening result directed the exact diagnosis. Eighty-two percent of the TP cases had good health outcomes, evaluated in 2020. The yearly positive predictive value was increased from 26% to 54% by the use of the Region 4 Stork post-analytical interpretive tool (R4S)/Collaborative Laboratory Integrated Reports 2.0 (CLIR), second-tier biochemical testing and genetic confirmation using DNA extracted from the original dried blood spots. The incidence of IEMs increased by 46% after eNBS was introduced, predominantly due to the finding of attenuated phenotypes. The next step is defining which newborns would truly benefit from screening at the milder end of the disease spectrum. This will require coordinated international collaboration, including proper case definitions and outcome studies.

Succinate-CoA ligase deficiency due to mutations in SUCLA2 and SUCLG1: phenotype and genotype correlations in 71 patients

BACKGROUND

The encephalomyopathic mtDNA depletion syndrome with methylmalonic aciduria is associated with deficiency of succinate-CoA ligase, caused by mutations in SUCLA2 or SUCLG1. We report here 25 new patients with succinate-CoA ligase deficiency, and review the clinical and molecular findings in these and 46 previously reported patients.

PATIENTS AND RESULTS

Of the 71 patients, 50 had SUCLA2 mutations and 21 had SUCLG1 mutations. In the newly-reported 20 SUCLA2 patients we found 16 different mutations, of which nine were novel: two large gene deletions, a 1 bp duplication, two 1 bp deletions, a 3 bp insertion, a nonsense mutation and two missense mutations. In the newly-reported SUCLG1 patients, five missense mutations were identified, of which two were novel. The median onset of symptoms was two months for patients with SUCLA2 mutations and at birth for SUCLG1 patients. Median survival was 20 years for SUCLA2 and 20 months for SUCLG1. Notable clinical differences between the two groups were hepatopathy, found in 38% of SUCLG1 cases but not in SUCLA2 cases, and hypertrophic cardiomyopathy which was not reported in SUCLA2 patients, but documented in 14% of cases with SUCLG1 mutations. Long survival, to age 20 years or older, was reported in 12% of SUCLA2 and in 10% of SUCLG1 patients. The most frequent abnormality on neuroimaging was basal ganglia involvement, found in 69% of SUCLA2 and 80% of SUCLG1 patients. Analysis of respiratory chain enzyme activities in muscle generally showed a combined deficiency of complexes I and IV, but normal histological and biochemical findings in muscle did not preclude a diagnosis of succinate-CoA ligase deficiency. In five patients, the urinary excretion of methylmalonic acid was only marginally elevated, whereas elevated plasma methylmalonic acid was consistently found.

CONCLUSIONS

To our knowledge, this is the largest study of patients with SUCLA2 and SUCLG1 deficiency. The most important findings were a significantly longer survival in patients with SUCLA2 mutations compared to SUCLG1 mutations and a trend towards longer survival in patients with missense mutations compared to loss-of-function mutations. Hypertrophic cardiomyopathy and liver involvement was exclusively found in patients with SUCLG1 mutations, whereas epilepsy was much more frequent in patients with SUCLA2 mutations compared to patients with SUCLG1 mutations. The mutation analysis revealed a number of novel mutations, including a homozygous deletion of the entire SUCLA2 gene, and we found evidence of two founder mutations in the Scandinavian population, in addition to the known SUCLA2 founder mutation in the Faroe Islands.

Genome instability in Maple Syrup Urine Disease correlates with impaired mitochondrial biogenesis

OBJECTIVE

The mitochondrial branched-chain ketoacid dehydrogenase (BCKD) catalyzes the degradation of branched-chain amino acids (BCAA), which have been shown to induce oxidative stress. Maple Syrup Urine Disease (MSUD) is caused by impaired activity of BCKD, suggesting that oxidative stress and resulting DNA damage could contribute to pathology. We evaluated the potential effect of BCKD deficiency on genome integrity and mitochondrial function as a downstream target.

METHODS

Primary fibroblasts from MSUD patients and controls were either cultivated under normal conditions or exposed to metabolic or oxidative stress. DNA was analyzed for damage and mitochondrial function was evaluated by gene expression analyses, functional assays and immunofluorescent methods.

RESULTS

Patient fibroblasts accumulated damage in mitochondrial DNA (mtDNA) and nuclear DNA, with a corresponding reduction in mitochondrial transcription, mtDNA copy number and pyruvate dehydrogenase. We found no evidence of increased level of reactive oxygen species (ROS) in patient fibroblasts under normal conditions, suggesting that the genotoxic effect is ascribed to accumulating metabolites.

CONCLUSIONS

Impaired BCKD activity as in MSUD, results in accumulation of DNA damage and corresponding mitochondrial dysfunction.

No effect of combined coenzyme Q10 and selenium supplementation on atorvastatin-induced myopathy

OBJECTIVE

The aim of the present study was to evaluate the possible effects of Q10 and selenium supplementation on statin-induced myopathy (SIM), both for subjective symptoms and muscle function.

DESIGN

Patients (N = 43) who had experienced previous or ongoing SIM on atorvastatin therapy were recruited. Following a 6-week washout period during which no statins were administered, the patients were re-challenged with 10 mg of atorvastatin. Patients (N = 41) who experienced SIM continued the atorvastatin treatment and were in addition randomized to receive 12 weeks supplement of 400 mg Q10 and 200 μg selenium per day or a matching double placebo. SIM was assessed using 3 validated symptom questionnaires, and a muscle function test was performed at the beginning and at the end of the study.

RESULTS

The patients receiving the active supplement experienced significant increases in their serum Q10 and selenium concentrations compared with the group receiving placebo. No statistically significant differences in symptom questionnaire scores or muscle function tests were revealed between the groups.

CONCLUSIONS

Despite substantial increases in the serum Q10 and selenium levels following the oral supplementation, this study revealed no significant effects on SIM compared with the placebo.

Hereditary tyrosinaemia type I in Norway: incidence and three novel small deletions in the fumarylacetoacetase gene

A total of 28 Norwegians have been diagnosed with hereditary tyrosinaemia type I (HT1) over the last 30 years. In this study, 19 of these patients were investigated. Three novel small deletions were found (NM_000137.1(FAH): c.615delT, p.Phe205LeufsX2, NM_000137.1(FAH): c.744delG, p.Pro249HisfsX55 and NM_000137.1(FAH):c835delC) pGln279ArgfsX25, all of them leading to a change in the reading frame and a premature stop codon. We hereby genetically characterized 51 of the 56 disease-causing alleles, identifying nine different disease-causing mutations in the Norwegian population. We found that 65% of the Norwegian HT1 patients are compound heterozygous for different mutations. Thus, the relatively high incidence of HT1 in Norway of 1 in 74,800 live births is not due to single founder effects or high incidence of parental consanguinity.

A novel mucopolysaccharidosis type I associated splice site mutation and IDUA splice variants

Mucopolysaccharidosis type I is an autosomal recessive disorder caused by deficiency of α-l-iduronidase, encoded by the IDUA gene. More than 100 disease causing mutations have been reported in the gene, resulting in a wide range of phenotypes. Here we describe a previously unreported IDUA splice site mutation (NG_008103.1:g.21632G>C; NM_000203.3:c.1727+3G>C) causing a Hurler phenotype in a patient heterozygous for the common p.Q70X (NG_008103.1:g.5862C>T) mutation. Sequence analysis of IDUA transcripts demonstrated that the g.21632G>C mutation results in aberrant splicing of intron 12 (NM_000203.3:c.1727_1728insGTCC), introducing a frame shift and premature termination codon (NP_000194.2:p.Cys577SerfsX15). Gene expression studies suggest that the deleterious effect of the mutation is primarily due to a C-terminal truncation of the encoded polypeptide. Furthermore, we observed that both normal and mutant IDUA alleles give rise to alternatively spliced transcripts in leukocytes. Exclusion of exon 4 appeared to be the predominant alternative splicing event, probably resulting in polypeptides lacking iduronidase activity. The Hurler patient demonstrated exon 4 skipping in 5.6% of IDUA transcripts, while exon 4 skipping ranged 25-34% of transcripts among healthy individuals (n=5). Alternative splicing might represent a mechanism for regulation of this enzyme, and the lower level of exon 4 skipping in the patient might be a response to intracellular accumulation of iduronidase substrates. Molecular characterization of IDUA mutations and splicing may assist early prediction of mucopolysaccharidosis type I phenotypes and increase the understanding of disease mechanisms. This is important considering the choice of current treatment options and for the development of future therapies.

Liquid chromatography-tandem mass spectrometry determination of oxalate in spot urine

BACKGROUND

For assessment of total oxalic acid (OX) status, reliable quantification of OX in both urine and plasma is important. For urine, but not plasma, a commercial kit is available. We have recently described a LC-MSMS method for OX in plasma. The aim of the present study was to evaluate the usefulness of this assay for urine. We also wanted to evaluate if 24 h urine collection could be substituted by OX/creatinine-ratio (U-OX/crea) in spot-urine, and establish precursory reference intervals for U-OX/crea in children and adults.

METHODS

Acidified urines were analysed and relevant validation parameters assessed. Diurnal excretion patterns were investigated in nine healthy volunteers on self-chosen diets. For method comparison, 29 urine samples were analysed with both the present method and a commercial urine-oxalate kit. Precursory reference values for U-OX/crea in children and adults (N=103, 1 month-76 years) were calculated.

RESULTS

The within-batch coefficient of variation (CV) was 2.5% and a relative recovery of 97% in urine spiked with 5-200 micromol/L OX was found. The LC-MSMS method gave 7.9% higher OX values compared to the kit. No significant diurnal pattern of U-OX/crea was observed. U-OX/crea in children decreases with age, with no gender dependency. In adults no age variation was found, but females had somewhat higher U-OX/Crea compared to males.

CONCLUSION

The LC-MSMS method has proven useful for urinary OX quantification. Random spot-urine samples can be used. Age-dependent reference limits for U-OX/crea must be applied in children, in contrast to adults.

Four novel mutations identified in Norwegian patients result in intermittent maple syrup urine disease when combined with the R301C mutation

Maple syrup urine disease (MSUD) is caused by a defect in branched chain alpha-ketoacid dehydrogenase complex (BCKD), an essential metabolon for the catabolism of the branched chain amino acids. Here, we report four novel mutations in the DBT gene, encoding the transacylase subunit (E2) of BCKD, resulting in intermittent MSUD in seven Norwegian patients. The patients had episodes with neurological symptoms including lethargy and/or ataxia during childhood infections. All seven patients were heterozygous for the annotated R301C mutation. The second allelic mutations were identified in five patients; one nonsense mutation (G62X), two missense mutations (W84C and R376C) and a mutation in the 3' untranslated region (UTR; c. *358A>C) in two patients. These four novel mutations result in near depletion of E2 protein, and the common R301C protein contributes predominantly to the residual (14%) cellular BCKD activity. Structural analyses of the mutations implied that the W84C and R376C mutations affect stability of intramolecular domains in E2, while the R301C mutation likely disturbs E2 trimer assembly as previously reported. The UTR mutated allele coincided with a strong reduction in mRNA levels, as did the non-R301C specific allele in two patients where the second mutation could not be identified. In summary, the pathogenic effect of the novel mutations is depletion of cellular protein, and the intermittent form of MSUD appears to be attributed to the residual R301C mutant protein in these patients.

Parental consanguinity is associated with a seven-fold increased risk of progressive encephalopathy: a cohort study from Oslo, Norway

BACKGROUND/OBJECTIVE

Progressive encephalopathy (PE) is a heterogeneous group of individually rare diseases, many with an autosomal recessive mode of inheritance. We estimated the increased risk of PE associated with consanguinity.

PATIENTS AND METHODS

Using a historic cohort study design, the exposures were country of origin (Pakistan versus Norway) and consanguinity. We included children living in Oslo, born between 1985 and 2003. PE cases were retrieved from an electronic registry of diagnoses coded according to the International Classification of Diseases. Incidence rates were calculated for country of origin. We also estimated population attributable risks caused by consanguinity.

RESULTS

We identified 30 cases per 79 704 person years with Pakistani origin and 35 cases per 658 932 person years with Norwegian origin. This gave incidence rates of 37.6 and 5.3 per 100 000 person years, whereas the incidence rate ratio was 7.1 (95% CI: 4.2-11.9). The incidence rates of consanguineous versus non-consanguineous of Pakistani origin were 59.6 and 18.7 per 100 000 person years. The incidence rate ratio was 3.2 (95% CI: 1.4-7.2), whereas the incidence rate ratio of non-consanguineous Pakistani versus non-consanguineous Norwegian origin was 3.5 (95% CI: 1.6-7.6). The incidence rate ratio between consanguineous Pakistanis and Norwegians was 11.2. The population attributable risk due to parental consanguinity was 50.3% in the Pakistani sub-population.

CONCLUSIONS

We found a seven-fold increased risk of PE in the general Pakistani population, and an eleven-fold increased risk in consanguineous Pakistanis. Pakistani origin by itself was also an independent risk factor. Avoidance of consanguinity in the Pakistani population would result in at least 50% reduction of PE in that group.

[A newborn infant with hyperventilation]

Respiratory alkalosis is an early sign of urea cycle disorder. A high level of plasma ammonia will strengthen this suspicion. It is of great importance to transfer the infant as soon as possible to a unit capable of giving specific treatment with Na-benzoate, Na-phenylbutyrate, argininchloride and carglumic acid. The early treatment may also include haemodialysis, which is preferred over peritoneal dialysis or exchange transfusion. We here describe an infant with respiratory alkalosis within the first two days of life and a high plasma level of ammonia (> 700 micromol/L). He did not respond to conventional therapy and died 48 hours after birth in spite of specific treatment. DNA-analysis showed a gene defect in the OTC gene, c.67C >T (p.R23X), a known mutation leading to urea cycle disorder (OTC). It is important to detect carriers among older siblings and to inform the parents of the possibility of prenatal diagnostics.

Mortality in childhood progressive encephalopathy from 1985 to 2004 in Oslo, Norway: a population-based study

AIMS

The aims were to estimate case fatality and survival rates, standardized mortality ratio (SMR), and independent prognostic factors for survival, in a population-based cohort of progressive encephalopathy (PE) patients.

METHODS

We divided onset of disease into neonatal and postneonatal groups and aetiology into metabolic (n=55), neurodegenerative (n=27) and HIV encephalopathy (n=2) groups. Case fatality was the number of deaths divided by the number of patients. Cumulative survival probability at 10 years of follow-up and independent risk factors for mortality were analyzed using the Kaplan-Meier survival curve and the Cox model.

RESULTS

Case fatality was 36.9% and the mean and median follow-up times were 3109 and 2887 days. At 1 and 10 years, the cumulative probability of survival was 81% and 66%. Neonatal onset showed increased risk of death compared to postneonatal onset (RR 3.0; 95% CI 1.4-6.2). Metabolic aetiology showed increased risk of death compared to other aetiology (RR 1.25; 95% CI 1.10-1.46). The SMR of 37.7 for boys and 23.8 for girls was significantly increased (p<0.001) compared to the total Norwegian population stratified by gender and age.

CONCLUSIONS

Children with PE showed a vast excess in mortality compared to the general population stratified by gender and age. Neonatal presentation and metabolic aetiology were the most significant factors for increased risk of death.

2-methylbutyryl-CoA dehydrogenase deficiency associated with autism and mental retardation: a case report

Background

2-methylbutyryl-CoA dehydrogenase deficiency or short/branched chain acyl-CoA dehydrogenase deficiency (SBCADD) is caused by a defect in the degradation pathway of the amino acid L-isoleucine.

Methods

We report a four-year-old mentally retarded Somali boy with autism and a history of seizures, who was found to excrete increased amounts of 2-methylbutyryl glycine in the urine. The SBCAD gene was examined with sequence analysis. His development was assessed with psychometric testing before and after a trial with low protein diet.

Results

We found homozygosity for A > G changing the +3 position of intron 3 (c.303+3A > G) in the SBCAD gene. Psychometric testing showed moderate mental retardation and behavioral scores within the autistic spectrum. No beneficial effect was detected after 5 months with a low protein diet.

Conclusion

This mutation was also found in two previously reported cases with SBCADD, both originating from Somalia and Eritrea, indicating that it is relatively prevalent in this population. Autism has not previously been described with mutations in this gene, thus expanding the clinical spectrum of SBCADD.

Incidence rates of progressive childhood encephalopathy in Oslo, Norway: a population based study

Background

Progressive encephalopathy (PE) in children is a heterogeneous group of diseases mainly composed of metabolic diseases, but it consists also of neurodegenerative disorders where neither metabolic nor other causes are found. We wanted to estimate the incidence rate and aetiology of PE, as well as the age of onset of the disease.

Methods

We included PE cases born between 1985 and 2003, living in Oslo, and registered the number presenting annually between 1985 and 2004. Person-years at risk between 0 and 15 years were based on the number of live births during the observation period which was divided into four 5-year intervals. We calculated incidence rates according to age at onset which was classified as neonatal (0–4 weeks), infantile (1–12 months), late infantile (1–5 years), and juvenile (6–12 years).

Results

We found 84 PE cases representing 28 diagnoses among 1,305,997 person years, giving an incidence rate of 6.43 per 100,000 person years. The age-specific incidence rates per 100,000 were: 79.89 (<1 year), 8.64 (1–2 years), 1.90 (2–5 years), and 0.65 (>5 years). 66% (55/84) of the cases were metabolic, 32% (27/54) were neurodegenerative, and 2% (2/84) had HIV encephalopathy. 71% (60/84) of the cases presented at < 1 year, 24% (20/84) were late infantile presentations, and 5% (4/84) were juvenile presentations. Neonatal onset was more common in the metabolic (46%) (25/55) compared to the neurodegenerative group (7%) (2/27). 20% (17/84) of all cases were classified as unspecified neurodegenerative disease.

Conclusion

The overall incidence rate of PE was 6.43 per 100,000 person years. There was a strong reduction in incidence rates with increasing age. Two-thirds of the cases were metabolic, of which almost half presented in the neonatal period.

[Mitochondrial beta-oxidation defects]

BACKGROUND

Mitochondrial beta-oxidation of fatty acids is an important source of energy for the cells, especially during fasting. Since 1973 several inherited defects in beta-oxidation have been described. Defects in mitochondrial beta-oxidation are one of the largest groups of inborn errors of metabolism.

MATERIAL AND METHODS

This review article is based on the experience of the authors and on literature studies. The authors' experience is from laboratory diagnostics and clinical experience in the departments of medical biochemistry and peadiatrics at our hospital.

RESULTS AND INTERPRETATION

Beta-oxidation defects are potentially fatal disorders. Symptoms are usually seen during fasting, e.g. during childhood infections. Organs which preferably oxidize fatty acids or ketone bodies are especially vulnerable. Often, but not always, the patients have hypoketotic hypoglycaemia. In addition one can see affection of the liver, heart, muscular and nervous systems. The diseases can manifest both in childhood and adulthood and are often less severe in adulthood. The main principles of symptomatic treatment are avoidance of fasting and regular intake of a low-fat, high-carbohydrate diet. The diagnosis can be difficult to establish, especially in asymptomatic phases.

Effect of intravenous bilirubin infusion on biliary phospholipid secretion, hepatic P-glycoprotein expression, and biliary cytotoxicity in pigs

BACKGROUND

Infusion of large intravenous bilirubin loads in bile acid-depleted pigs reduces P-glycoprotein-dependent biliary phospholipid secretion and increases the cytotoxicity of bile. The reasons for the diminution of biliary phospholipid secretion and the increase in biliary cytotoxicity are not known. This study was undertaken to determine whether the bilirubin-induced lowering of biliary phospholipid secretion is associated with alterations in hepatic P-glycoprotein (P-gp) expression and to determine why bilirubin infusions increase biliary cytotoxicity.

METHODS

Hepatic bile was collected from bile acid-depleted pigs before and during intravenous bilirubin infusion. Hepatic P-gp expression was measured with protein blot analysis, using the P-gp-specific antibody C219. Biliary cytotoxicity was assayed against erythrocytes. The biliary phospholipid fatty acid profile was determined by means of gas chromatography.

RESULTS

Bilirubin infusions lowered biliary phospholipid secretion by 69% without changing hepatic P-gp expression, suggesting that bilirubin infusions have an inhibitory effect on hepatic P-gp activity. Bilirubin infusions did not cause P-gp losses into bile. An unequivocal, proportional relationship (r2 = 0.80) pertained between cytotoxicity and the bile acid to phospholipid ratio in bile secreted before and during bilirubin infusion and in phosphatidylcholine-supplemented bile. Unconjugated bilirubin in bile did not contribute to biliary cytotoxicity. Biliary phospholipids were always phosphatidylcholine >> phosphatidylethanolamine, mainly of C16:0, 18:2 and C16:0, 18:1 fatty acid configuration.

CONCLUSIONS

Intravenous bilirubin loads reduce biliary phospholipid secretion without changing hepatic P-gp expression. Bilirubin infusions increase biliary cytotoxicity by augmenting the biliary bile acid to phospholipid ratio.

Monounsaturated trans fatty acids, elaidic acid and trans-vaccenic acid, metabolism and incorporation in phospholipid molecular species in hepatocytes

The incorporation of [14C]elaidic acid (trans18:1(n-9)) in phosphatidylcholine and phosphatidylethanolamine molecular species in isolated rat liver cells has been studied, and the results compared with the incorporation, previously published (B. Woldseth et al. Biochim Biophys Acta 1993; 1167: 296-302), of [14C]palmitic acid (16:0) and [14C]stearic acid (18:0) and with that of [14C]oleic acid (cis18:1(n-9)). The pattern of incorporation in phospholipid molecular species is similar to that of [14C]stearic acid and different from that of [14C]palmitic acid. In phosphatidylcholine [14C]trans18:1-18:2 and [14C]trans18:1-20:4 were the most abundant species, and in phosphatidylethanolamine [14C]trans18:1-20:4 was the predominant species. With increasing concentration of [14C]elaidic acid increasing amounts of [14C]trans18:1-[14C]trans18:1 were found. The total incorporation in phospholipids was less than that of [14C]stearic acid, but more than that of [14C]palmitic acid. The distribution in percent of [14C]elaidic acid in phospholipid classes was 8.8% in phosphatidylinositol, 1.8% in phosphatidylserine, 59.1% in phosphatidylcholine and 30.3% in phosphatidylethanolamine with 0.1 mmol l-1 substrate concentration. More [14C]elaidic acid than [14C]palmitic acid or [14C]stearic acid was oxidized. The incorporation in phospholipids of [14C]elaidic acid was very different from that of [14C]oleic acid. The main species with [14C]oleic acid were 16:0-[14C]cis18:1 in phosphatidylcholine, and [14C]cis18:1-20:4 in phosphatidylethanolamine. In some experiments [14C]18:2(n-6) was incubated together with unlabelled elaidic or unlabelled trans-vaccenic acid (trans18:1(n-7)). In these experiments, more trans18:1-18:2 was formed from elaidic acid than from trans-vaccenic acid, especially in phosphatidylethanolamine.

A comparative study of the metabolism of n-9, n-6 and n-3 fatty acids in testicular cells from immature rat

Dietary 18 and 20-carbon fatty acids of the n-6 and the n-3 families are metabolized to 22:5,n-6 and 22:6,n-3 by a sequence of specific desaturases and chain elongation via 24-carbon intermediates. This pathway is regulated so that more 22:6,n-3 than 22:5,n-6 is found in the tissues. Rat testis is an exception since 22:5,n-6 is present in large proportions in this organ. Therefore rat testis appears to be interesting for studies of the detailed synthesis of 22:5,n-6 compared with that of 22:6,n-3. By using fresh preparations of rat testicular cells from 19-day-old rats enriched in Sertoli cells, we compared the metabolism of 1-14C-labelled n-3, n-6 and n-9 fatty acids. The testicular cells actively synthesized 22:6,n-3 and 22:5, n-6, but not 22:4,n-9 from the 18 and 20-carbon precursors. Of 200 mol 14C-labelled C18 and C20 fatty acids added initially, approximately 20-40 mol were found as 24-carbon intermediates after 24 h of incubation. This indicates that the balanced capacity of elongation, desaturation and chain shortening favours the accumulation of 24-carbon intermediates in these cells. One exception was [1-14C]20:3,n-9 which was efficiently elongated to 22:3,n-9 but not to C24 fatty acids. Our data suggests that the poor elongation of n-9 fatty acids from C22- to C24 may be an important hindrance in the synthesis of 22:4,n-9. The efficient synthesis of 22:5,n-6 may also partly explain why this is the major 22-carbon fatty acid in rat testis.

Membrane fluidity and fatty acid metabolism in kidney cells from rats fed purified eicosapentaenoic acid or purified docosahexaenoic acid

Rats were given a supplement (1.5 ml/day) of purified eicosapentaenoic acid (EPA, 20:5,n-3), purified docosahexaenoic acid (DHA, 22:6,n-3)), or corn oil for 10 days. Membrane fluidity, measured as the steady-state fluorescence polarization of diphenylhexatriene (DPH), was approximately 20% lower in kidney cells from rats fed purified EPA than in cells from the DHA-fed or corn-oil fed animals. The level of 20:5(n-3) in kidney phospholipids was 18 times higher in rats fed EPA, and four times higher in those fed DHA as compared to the corn-oil group. The level of arachidonic acid (20:4,n-6) was concomitantly decreased, while linoleic acid (18:2,n-6) was increased in kidney-phospholipids in the n-3 fatty acid fed rats. The proportion of 22:6(n-3) in kidney phospholipids was not affected by EPA supplementation, while the DHA diet slightly increased the level of this fatty acid. The distribution of phospholipid subclasses was significantly altered in that phosphatidylcholine was increased and phosphatidylethanolamine was concomitantly decreased. It is suggested that the decrease in 20:4(n-6) is relatively more important in the regulation of fluidity than a concomitant increase in 20:5(n-3). It is also suggested that the compensatory modifications of the phospholipid subclass distribution as a response to decreased 20:4(n-6)/20:5(n-3) ratio was not sufficient to maintain fluidity when the ratio was as low as in the present study. The incorporation of labelled linolenic acid (18:3,n-3) in phospholipids was decreased in cells from the n-3 supplemented rats. Since endogenous 22:5(n-3) in phospholipids was only increased in the EPA group, 22:6(n-3) only in the DHA group, and 20:5(n-3) in both, it is suggested that the decreased incorporation of labelled 18:3(n-3) into phospholipids of the DHA-fed rats in particular is correlated to the increased level of 22:6(n-3) in the membrane phospholipids. The incorporation of fatty acids into phopholipids may thus show substrate specificity, in that 22:6(n-3) is less exchangable with labelled 18:3(n-3) than is 20:5(n-3). These results demonstrate that increasing levels of n-3 fatty acids in membranes affect the uptake and intracellular metabolism of fatty acids as well as membrane fluidity in the kidney.

The metabolism of 22:5(-6) and of docosahexaenoic acid [22:6(-3)] compared in rat hepatocytes

Elevated levels of 22:5(-6), which is the elongated and desaturated product of arachidonic acid, is induced by selective n-3 fatty acid deficiency, especially in brain cortex. Less elongation and desaturation of 20:4(-6) than of 20:5(-3) has been found in intact rat liver cells in previous studies and is probably the main reason why so little 22:5(-6) is found under adequate nutritional conditions. The present study compares the metabolism of 22:5(-6) with the metabolism of 22:6(-3), the main n-3 fatty acid in mammals. Freshly isolated rat liver cells were incubated with [1-14C]22:5(-6) and [1-14C]22:6(-3). Oxidation and esterification in triacylglycerols, diacylglycerols and phospholipids were studied. The phospholipid classes were separated and the different molecular species identified. Rats with essential fatty acid deficiency were compared with control rats. 22:5(-6) was found to be a good substrate for membrane phospholipid biosynthesis and was conserved well in the phospholipid fraction of the rat liver cells for more than 3 h of incubation. More 22:5(-6) was esterified in the total phospholipid fraction and less was incorporated in triacylglycerols than observed with 22:6(-3) in hepatocytes from control animals. This was not the case in animals with essential fatty acid deficiency. 22:5(-6) was esterified to a greater extent in phosphatidylcholine than 22:6(-3) in control cells but not in essential fatty acid deficiency cells. More 22:5(-6) was coupled with 18.0 in the sn-1 position of the phospholipid molecular species than 22:6(-3) was in control cells.

Studies on the metabolism of [1-14C]5.8.11-eicosatrienoic (Mead) acid in rat hepatocytes

The oxidation, esterification and formation of chain elongated and desaturated products of [1-14C]5,8,11-eicosatrienoic (Mead) acid was studied. Liver cells from essentially fatty acid deficient (EFAD) and control rats were used. The metabolism of [1-14C]20:4, n-6 and [1-14C]20:5, n-3 were studied under the same experimental conditions. More 20:3, n-9 than 20:4, n-6 and 20:5, n-3 was oxidised both in EFAD and control cells. 20:3, n-9 was elongated to [14C]22:3, n-9 in both cell types and significant amounts of [14C]22:4, n-9 were formed in EFAD cells. Less 20:3, n-9 was esterified in phospholipids and more in triacylglycerol than observed with 20:4, n-6 and 20:5, n-3 in both cell types. 20:3, n-9 was mainly esterified in phosphatidylcholine and little was esterified in phosphatidylethanolamine compared to 20:4, n-6 and 20:5, n-3. In comparison, 20:3, n-9 was rather efficiently esterified in phosphatidylinositol as 18:0-20:3. [14C]22:4, n-9 formed from 20:3, n-9 in EFAD hepatocytes was esterified in triacylglycerol, not in phospholipids, unlike [14C]22:5, n-6 and [14C]22:6, n-3 which were mainly esterified in phospholipids.

Phospholipid molecular species with eicosapentaenoic acid (20:5(n-3)) are less stable than species with arachidonic acid (20:4(n-6)) in isolated rat liver cells

We have studied the incorporation of [1-14C]20:5(n-3) and [1-14C]20:4(n-6) in the molecular species of phosphatidylcholine (PC) and phosphatidylethanolamine (PE) in isolated rat liver cells. These two fatty acids are present in very different amounts in endogenous phospholipids, with 20:4 as one of the major fatty acids and 20:5 as a minor and very diet-dependent constituent. The main phospholipid species formed from 20:4(n-6) were 16:0-20:4 and 18:0-20:4. When formed, they were stable during incubations of liver cells for 2-3 h. The main species formed from 20:5(n-3) were 16:0-20:5 and 18:0-20:5. After formation, 16:0-20:5 and to a lesser degree 18:0-20:5 were, however, degraded during 1-2 h of incubation, especially in PC. Only small amounts of 22:5(n-3) and very little 22:6(n-3) were formed from 20:5(n-3) and small amounts of 22:4(n-6) were produced from 20:4(n-6). With 20:4(n-6) and 20:5(n-3) as substrates, 20:4-20:4 and 20:5-20:5 molecular species respectively were initially formed in PC and PE but both species were rapidly degraded.

Biosynthesis of phospholipid molecular species in isolated liver cells studied by combining fatty acid substrates esterified in the sn-1 and sn-2 positions

The simultaneous incorporation of a saturated fatty acid in the sn-1 position and an unsaturated fatty acid in the sn-2 position in phosphatidylcholine (PC) and ethanolamine (PE) was studied in isolated liver cells. We combined a saturated fatty acid, 16:0 or 18:0 and an unsaturated fatty acid substrate, 18:2,n-6 or 20:4,n-6. In this situation the saturated fatty acids were preferentially oxidized and the unsaturated fatty acids were preferentially esterified in PL and TG. Addition of unlabelled 16:0 increased the incorporation of [14C]18:2 in 16:0-18:2 in PC and PE, reduced the incorporation in 18:2-18:2 but did not reduce the incorporation in 18:0-18:2. 18:0 increased the esterification of [14C]18:2 in 18:0-18:2, reduced the incorporation in 18:2-18:2 but did not reduce the incorporation in 16:0-18:2. The latter is the dominating 14C-labelled species formed from [14C]18:2 also in the presence of unlabelled 18:0. Addition of 20:4 stimulated the incorporation of [14C]16:0 in 16:0-20:4 and markedly reduced the formation of 16:0-18:2, 16:0-18:1 and 16:0-22:6. Addition of 18:2 increased the incorporation of [14C]16:0 in 16:0-18:2 and reduced the formation of 16:0-20:4 and 16:0-18:1. It is concluded that the unsaturated fatty acids 18:2 or 20:4 have a stronger impact on the synthesis of phospholipid molecular species than the saturated fatty acids 16:0 or 18:0 have. Thus 20:4,n-6 and 18:2,n-6 are able to direct available [14C]16:0 or [14C]18:0 to the sn-1 position. 16:0 and 18:0 are not in the same way able to direct [14C]18:2,n-6 to the synthesis of 16:0-18:2 or 18:0-18:2 at the expense of other 14C-labelled molecular species.

Incorporation of stearic acid (18:0) and palmitic acid (16:0) in phospholipid molecular species studied in isolated rat liver cells

The incorporation of [1-14C]16:0 and [1-14C]18:0 in the molecular species of PC and PE in isolated rat liver cells was studied. More [14C]18:0 than [14C]16:0 was esterified both in PC and PE. Also the chain elongated and desaturated products (16:1, 18:0 and 18:1) were incorporated. The main molecular phospholipid species formed from [14C]18:0 were 18:0-18:2, 18:0-20:4 and 18:0-22:6. 18:0-18:0 species was not detected, independent of the substrate concentration (0.1-0.9 mM). With [14C]16:0 at low substrate concentration (0.1 mM) the dominating species are 16:0-18:2, 16:0-20:4 and 16:0-22:6. These species were detected already after 10 min. The same main species are formed both in PC and PE, but the relative amounts differ. In PC the combination with 18:2 is most abundant for both saturated fatty acid substrates. In PE 18:0-20:4 dominates when 18:0 is the substrate, and 16:0-22:6 when 16:0 is. At higher substrate concentrations (0.4-0.9 mM) 16:0 is also esterified in 16:0-16:0. This molecular species is efficiently degraded in the cells within 2-3 h, in contrast to the other species formed. The results suggest that 16:0 and 18:0 are directly incorporated in the sn-1 position in physiologically important phospholipid molecular species. With an excess of 16:0, 16:0-16:0 is also formed in substantial amounts, but this uncommon species is thereafter removed.

Peroxisomal beta-oxidation of polyunsaturated long chain fatty acids in human fibroblasts. The polyunsaturated and the saturated long chain fatty acids are retroconverted by the same acyl-CoA oxidase

The metabolism of the C22 unsaturated fatty acids erucic acid (22:1(n-9)), adrenic acid (22:4(n-6)), docosapentaenoic acid (22:5(n-3)) and docosahexaenoic acid (22:6(n-3)) was studied in cultured fibroblasts from patients with acyl-CoA oxidase deficiency, the Zellweger syndrome, X-linked adrenoleukodystrophy (X-ALD) and normal controls. [3-14C] 22:4 (n-6) and [3-14C] 22:5 (n-3) were shortened (retroconverted) to [1-14C] 20:4 (n-6) and [1-14C] 20:5 (n-3), respectively, in normal and X-ALD fibroblasts. In Zellweger and acyl-CoA oxidase deficient fibroblasts these reactions were deficient. Since the retroconversion is normal in X-ALD fibroblasts peroxisomal very long chain (lignoceryl) CoA ligase is probably not required for the activation of C22 unsaturated fatty acids. The present work with fibroblasts from patients with a specific acyl-CoA oxidase deficiency, previously shown to have a deficient peroxisomal clofibrate-inducible acyl-CoA oxidase, and which accumulate 24:0 and 26:0 fatty acids, supports the view that this enzyme is responsible for the chain-shortening of docosahexaenoic acid (22:6(n-3)), erucic acid (22:1(n-9)), docosapentaenoic acid (22:5(n-3)), and adrenic acid (22:4(n-6)) as well.