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Ryder B, Inbar-Feigenberg M, Glamuzina E, Halligan R, Vara R, Elliot A, Coman D, Minto T, Lewis K, Schiff M, Vijay S, Akroyd R, Thompson S, MacDonald A, Woodward AJM, Gribben JEL, Grunewald S, Belaramani K, Hall M, van der Haak N, Devanapalli B, Tolun AA, Wilson C, Bhattacharya K. New insights into carnitine-acylcarnitine translocase deficiency from 23 cases: Management challenges and potential therapeutic approaches. J Inherit Metab Dis 2021; 44:903-915. [PMID: 33634872 DOI: 10.1002/jimd.12371] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 02/19/2021] [Accepted: 02/23/2021] [Indexed: 12/22/2022]
Abstract
Carnitine acyl-carnitine translocase deficiency (CACTD) is a rare autosomal recessive disorder of mitochondrial long-chain fatty-acid transport. Most patients present in the first 2 days of life, with hypoketotic hypoglycaemia, hyperammonaemia, cardiomyopathy or arrhythmia, hepatomegaly and elevated liver enzymes. Multi-centre international retrospective chart review of clinical presentation, biochemistry, treatment modalities including diet, subsequent complications, and mode of death of all patients. Twenty-three patients from nine tertiary metabolic units were identified. Seven attenuated patients of Pakistani heritage, six of these homozygous c.82G>T, had later onset manifestations and long-term survival without chronic hyperammonemia. Of the 16 classical cases, 15 had cardiac involvement at presentation comprising cardiac arrhythmias (9/15), cardiac arrest (7/15), and cardiac hypertrophy (9/15). Where recorded, ammonia levels were elevated in all but one severe case (13/14 measured) and 14/16 had hypoglycaemia. Nine classical patients survived longer-term-most with feeding difficulties and cognitive delay. Hyperammonaemia appears refractory to ammonia scavenger treatment and carglumic acid, but responds well to high glucose delivery during acute metabolic crises. High-energy intake seems necessary to prevent decompensation. Anaplerosis utilising therapeutic d,l-3-hydroxybutyrate, Triheptanoin and increased protein intake, appeared to improve chronic hyperammonemia and metabolic stability where trialled in individual cases. CACTD is a rare disorder of fatty acid oxidation with a preponderance to severe cardiac dysfunction. Long-term survival is possible in classical early-onset cases with long-chain fat restriction, judicious use of glucose infusions, and medium chain triglyceride supplementation. Adjunctive therapies supporting anaplerosis may improve longer-term outcomes.
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Affiliation(s)
- Bryony Ryder
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, Ontario, Canada
- National Metabolic Service, Starship Children's Hospital, Auckland, New Zealand
| | - Michal Inbar-Feigenberg
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Emma Glamuzina
- National Metabolic Service, Starship Children's Hospital, Auckland, New Zealand
| | - Rebecca Halligan
- Department of Inherited Metabolic Disorders, Birmingham Women's and Children's Hospital Foundation Trust, Birmingham, UK
- Department of Metabolic Medicine, Evelina Children's Hospital, London, UK
| | - Roshni Vara
- Department of Metabolic Medicine, Evelina Children's Hospital, London, UK
| | - Aoife Elliot
- Queensland Lifespan Metabolic Medicine Service, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - David Coman
- Queensland Lifespan Metabolic Medicine Service, Queensland Children's Hospital, Brisbane, QLD, Australia
- School of Medicine University of Queensland and Griffith University, Brisbane, Queensland, Australia
| | - Tahlee Minto
- Queensland Lifespan Metabolic Medicine Service, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Katherine Lewis
- Queensland Lifespan Metabolic Medicine Service, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Manuel Schiff
- Reference Centre for Inherited Metabolic Diseases, AP-HP, Necker University Hospital, University of Paris, Paris, France
- INSERM U1163, Institut Imagine, Paris, France
| | - Suresh Vijay
- Department of Inherited Metabolic Disorders, Birmingham Women's and Children's Hospital Foundation Trust, Birmingham, UK
| | - Rhonda Akroyd
- National Metabolic Service, Starship Children's Hospital, Auckland, New Zealand
| | - Sue Thompson
- Department of Metabolic Genetics, Sydney Children's Hospitals' Network NSW, Sydney, New South Wales, Australia
- Faculty of Health and Medical Science, University of Sydney, Sydney, New South Wales, Australia
| | - Anita MacDonald
- Department of Inherited Metabolic Disorders, Birmingham Women's and Children's Hospital Foundation Trust, Birmingham, UK
| | - Abigail J M Woodward
- Department of Nutrition & Dietetics, Evelina London Children's Hospital, London, UK
| | - Joanne E L Gribben
- Department of Nutrition & Dietetics, Evelina London Children's Hospital, London, UK
| | - Stephanie Grunewald
- Metabolic Medicine Department, Great Ormond Street Hospital, Institute of Child Health University College London, NIHR Biomedical Research Centre, London, UK
| | - Kiran Belaramani
- Department of Metabolic Medicine, Hong Kong Children's Hospital, Ngau Tau Kok, Hong Kong
| | - Madeleine Hall
- Departments of Metabolic Medicine & Nutrition, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Natalie van der Haak
- Departments of Metabolic Medicine & Nutrition, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Beena Devanapalli
- Department of Metabolic Genetics, Sydney Children's Hospitals' Network NSW, Sydney, New South Wales, Australia
| | - Adviye Ayper Tolun
- Department of Metabolic Genetics, Sydney Children's Hospitals' Network NSW, Sydney, New South Wales, Australia
| | - Callum Wilson
- National Metabolic Service, Starship Children's Hospital, Auckland, New Zealand
| | - Kaustuv Bhattacharya
- Department of Metabolic Genetics, Sydney Children's Hospitals' Network NSW, Sydney, New South Wales, Australia
- Faculty of Health and Medical Science, University of Sydney, Sydney, New South Wales, Australia
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