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Moedas MF, Simões RJM, Silva MFB. Mitochondrial targets in hyperammonemia: Addressing urea cycle function to improve drug therapies. Biochem Pharmacol 2024; 222:116034. [PMID: 38307136 DOI: 10.1016/j.bcp.2024.116034] [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: 10/28/2023] [Revised: 12/27/2023] [Accepted: 01/25/2024] [Indexed: 02/04/2024]
Abstract
The urea cycle (UC) is a critically important metabolic process for the disposal of nitrogen (ammonia) produced by amino acids catabolism. The impairment of this liver-specific pathway induced either by primary genetic defects or by secondary causes, namely those associated with hepatic disease or drug administration, may result in serious clinical consequences. Urea cycle disorders (UCD) and certain organic acidurias are the major groups of inherited rare diseases manifested with hyperammonemia (HA) with UC dysregulation. Importantly, several commonly prescribed drugs, including antiepileptics in monotherapy or polytherapy from carbamazepine to valproic acid or specific antineoplastic agents such as asparaginase or 5-fluorouracil may be associated with HA by mechanisms not fully elucidated. HA, disclosing an imbalance between ammoniagenesis and ammonia disposal via the UC, can evolve to encephalopathy which may lead to significant morbidity and central nervous system damage. This review will focus on biochemical mechanisms related with HA emphasizing some poorly understood perspectives behind the disruption of the UC and mitochondrial energy metabolism, namely: i) changes in acetyl-CoA or NAD+ levels in subcellular compartments; ii) post-translational modifications of key UC-related enzymes, namely acetylation, potentially affecting their catalytic activity; iii) the mitochondrial sirtuins-mediated role in ureagenesis. Moreover, the main UCD associated with HA will be summarized to highlight the relevance of investigating possible genetic mutations to account for unexpected HA during certain pharmacological therapies. The ammonia-induced effects should be avoided or overcome as part of safer therapeutic strategies to protect patients under treatment with drugs that may be potentially associated with HA.
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Affiliation(s)
- Marco F Moedas
- Research Institute for Medicines-iMed.ULisboa, Faculty of Pharmacy, Universidade de Lisboa, Av. Prof. Gama Pinto, 1649-003 Lisboa, Portugal; Centre for Inherited Metabolic Diseases, Karolinska University Hospital, Stockholm, Sweden; Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Ricardo J M Simões
- Research Institute for Medicines-iMed.ULisboa, Faculty of Pharmacy, Universidade de Lisboa, Av. Prof. Gama Pinto, 1649-003 Lisboa, Portugal
| | - Margarida F B Silva
- Research Institute for Medicines-iMed.ULisboa, Faculty of Pharmacy, Universidade de Lisboa, Av. Prof. Gama Pinto, 1649-003 Lisboa, Portugal.
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2
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Sriretnakumar V, Harripaul R, Kennedy JL, So J. When rare meets common: Treatable genetic diseases are enriched in the general psychiatric population. Am J Med Genet A 2024:e63609. [PMID: 38532509 DOI: 10.1002/ajmg.a.63609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 03/06/2024] [Accepted: 03/13/2024] [Indexed: 03/28/2024]
Abstract
Mental illnesses are one of the biggest contributors to the global disease burden. Despite the increased recognition, diagnosis and ongoing research of mental health disorders, the etiology and underlying molecular mechanisms of these disorders are yet to be fully elucidated. Moreover, despite many treatment options available, a large subset of the psychiatric patient population is nonresponsive to standard medications and therapies. There has not been a comprehensive study to date examining the burden and impact of treatable genetic disorders (TGDs) that can present with neuropsychiatric features in psychiatric patient populations. In this study, we test the hypothesis that TGDs that present with psychiatric symptoms are more prevalent within psychiatric patient populations compared to the general population by performing targeted next-generation sequencing of 129 genes associated with 108 TGDs in a cohort of 2301 psychiatric patients. In total, 48 putative affected and 180 putative carriers for TGDs were identified, with known or likely pathogenic variants in 79 genes. Despite screening for only 108 genetic disorders, this study showed a two-fold (2.09%) enrichment for genetic disorders within the psychiatric population relative to the estimated 1% cumulative prevalence of all single gene disorders globally. This strongly suggests that the prevalence of these, and most likely all, genetic diseases is greatly underestimated in psychiatric populations. Increasing awareness and ensuring accurate diagnosis of TGDs will open new avenues to targeted treatment for a subset of psychiatric patients.
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Affiliation(s)
- Venuja Sriretnakumar
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Ricardo Harripaul
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
- Institute of Medical Science, University of Toronto, Toronto, Canada
| | - James L Kennedy
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
- Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Joyce So
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
- Department of Psychiatry, University of Toronto, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Division of Medical Genetics, Departments of Medicine and Pediatrics, University of California, San Francisco, California, USA
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3
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Siri B, Olivieri G, Lepri FR, Poms M, Goffredo BM, Commone A, Novelli A, Häberle J, Dionisi-Vici C. Father-to-daughter transmission in late-onset OTC deficiency: an underestimated mechanism of inheritance of an X-linked disease. Orphanet J Rare Dis 2024; 19:3. [PMID: 38167094 PMCID: PMC10763478 DOI: 10.1186/s13023-023-02997-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 12/13/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Ornithine Transcarbamylase Deficiency (OTCD) is an X-linked urea cycle disorder characterized by acute hyperammonemic episodes. Hemizygous males are usually affected by a severe/fatal neonatal-onset form or, less frequently, by a late-onset form with milder disease course, depending on the residual enzymatic activity. Hyperammonemia can occur any time during life and patients could remain non- or mis-diagnosed due to unspecific symptoms. In heterozygous females, clinical presentation varies based on the extent of X chromosome inactivation. Maternal transmission in X-linked disease is the rule, but in late-onset OTCD, due to the milder phenotype of affected males, paternal transmission to the females is possible. So far, father-to-daughter transmission of OTCD has been reported only in 4 Japanese families. RESULTS We identified in 2 Caucasian families, paternal transmission of late-onset OTCD with severe/fatal outcome in affected males and 1 heterozygous female. Furthermore, we have reassessed the pedigrees of other published reports in 7 additional families with evidence of father-to-daughter inheritance of OTCD, identifying and listing the family members for which this transmission occurred. CONCLUSIONS Our study highlights how the diagnosis and pedigree analysis of late-onset OTCD may represent a real challenge for clinicians. Therefore, the occurrence of paternal transmission in OTCD should not be underestimated, due to the relevant implications for disease inheritance and risk of recurrence.
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Affiliation(s)
- Barbara Siri
- Division of Metabolic Diseases and Hepatology, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy.
- Department of Paediatrics, Città della Salute e della Scienza, OIRM, University of Turin, Turin, Italy.
| | - Giorgia Olivieri
- Division of Metabolic Diseases and Hepatology, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Francesca Romana Lepri
- Translational Cytogenomics Research Unit, Laboratory of Medical Genetics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Martin Poms
- Division of Clinical Chemistry and Biochemistry and Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Bianca Maria Goffredo
- Division of Metabolism and Metabolic Diseases Research Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Anna Commone
- Division of Metabolic Diseases and Hepatology, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Antonio Novelli
- Translational Cytogenomics Research Unit, Laboratory of Medical Genetics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Johannes Häberle
- Division of Metabolism and Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Carlo Dionisi-Vici
- Division of Metabolic Diseases and Hepatology, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
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4
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Seker Yilmaz B, Baruteau J, Chakrapani A, Champion M, Chronopoulou E, Claridge LC, Daly A, Davies C, Davison J, Dhawan A, Grunewald S, Gupte GL, Heaton N, Lemonde H, McKiernan P, Mills P, Morris AA, Mundy H, Pierre G, Rajwal S, Sivananthan S, Sreekantam S, Stepien KM, Vara R, Yeo M, Gissen P. Liver transplantation in ornithine transcarbamylase deficiency: A retrospective multicentre cohort study. Mol Genet Metab Rep 2023; 37:101020. [PMID: 38053940 PMCID: PMC10694733 DOI: 10.1016/j.ymgmr.2023.101020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/01/2023] [Indexed: 12/07/2023] Open
Abstract
Ornithine transcarbamylase deficiency (OTCD) is an X-linked defect of ureagenesis and the most common urea cycle disorder. Patients present with hyperammonemia causing neurological symptoms, which can lead to coma and death. Liver transplantation (LT) is the only curative therapy, but has several limitations including organ shortage, significant morbidity and requirement of lifelong immunosuppression. This study aims to identify the characteristics and outcomes of patients who underwent LT for OTCD. We conducted a retrospective study for OTCD patients from 5 UK centres receiving LT in 3 transplantation centres between 2010 and 2022. Patients' demographics, family history, initial presentation, age at LT, graft type and pre- and post-LT clinical, metabolic, and neurocognitive profile were collected from medical records. A total of 20 OTCD patients (11 males, 9 females) were enrolled in this study. 6/20 had neonatal and 14/20 late-onset presentation. 2/20 patients had positive family history for OTCD and one of them was diagnosed antenatally and received prospective treatment. All patients were managed with standard of care based on protein-restricted diet, ammonia scavengers and supplementation with arginine and/or citrulline before LT. 15/20 patients had neurodevelopmental problems before LT. The indication for LT was presence (or family history) of recurrent metabolic decompensations occurring despite standard medical therapy leading to neurodisability and quality of life impairment. Median age at LT was 10.5 months (6-24) and 66 months (35-156) in neonatal and late onset patients, respectively. 15/20 patients had deceased donor LT (DDLT) and 5/20 had living related donor LT (LDLT). Overall survival was 95% with one patient dying 6 h after LT. 13/20 had complications after LT and 2/20 patients required re-transplantation. All patients discontinued dietary restriction and ammonia scavengers after LT and remained metabolically stable. Patients who had neurodevelopmental problems before LT persisted to have difficulties after LT. 1/5 patients who was reported to have normal neurodevelopment before LT developed behavioural problems after LT, while the remaining 4 maintained their abilities without any reported issues. LT was found to be effective in correcting the metabolic defect, eliminates the risk of hyperammonemia and prolongs patients' survival.
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Affiliation(s)
- Berna Seker Yilmaz
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK
| | - Julien Baruteau
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK
- Department of Paediatric Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - Anupam Chakrapani
- Department of Paediatric Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - Michael Champion
- Department of Inherited Metabolic Disease, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, SE1 7EH London, UK
| | - Efstathia Chronopoulou
- Department of Inherited Metabolic Disease, Division of Women's and Children's Services, University Hospitals Bristol NHS Foundation Trust, Bristol BS1 3NU, UK
| | | | - Anne Daly
- Birmingham Women's and Children's Hospital NHS Foundation Trust, B4 6NH, Birmingham, UK
| | - Catherine Davies
- Department of Inherited Metabolic Disease, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, SE1 7EH London, UK
| | - James Davison
- Department of Paediatric Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - Anil Dhawan
- Paediatric Liver Gastroenterology and Nutrition Centre and Mowat Labs, King's College Hospital NHS Foundation Trust, WC2R 2LS, London, UK
| | - Stephanie Grunewald
- Department of Paediatric Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - Girish L. Gupte
- Birmingham Women's and Children's Hospital NHS Foundation Trust, B4 6NH, Birmingham, UK
| | - Nigel Heaton
- Institute of Liver Studies, Kings College Hospital, Denmark Hill, WC2R 2LS London, UK
| | - Hugh Lemonde
- Department of Inherited Metabolic Disease, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, SE1 7EH London, UK
| | - Pat McKiernan
- Birmingham Women's and Children's Hospital NHS Foundation Trust, B4 6NH, Birmingham, UK
| | - Philippa Mills
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK
| | - Andrew A.M. Morris
- Willink Unit, Genetic Medicine, Manchester Academic Health Sciences Centre, Central Manchester University Hospitals NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
| | - Helen Mundy
- Department of Inherited Metabolic Disease, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, SE1 7EH London, UK
| | - Germaine Pierre
- Department of Inherited Metabolic Disease, Division of Women's and Children's Services, University Hospitals Bristol NHS Foundation Trust, Bristol BS1 3NU, UK
| | - Sanjay Rajwal
- Leeds Teaching Hospitals NHS Trust, LS9 7TF Leeds, UK
| | - Siyamini Sivananthan
- Department of Paediatric Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - Srividya Sreekantam
- Birmingham Women's and Children's Hospital NHS Foundation Trust, B4 6NH, Birmingham, UK
| | - Karolina M. Stepien
- Adult Inherited Metabolic Diseases, Salford Royal NHS Foundation Trust, M6 8HD Salford, UK
| | - Roshni Vara
- Department of Inherited Metabolic Disease, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, SE1 7EH London, UK
| | - Mildrid Yeo
- Department of Paediatric Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - Paul Gissen
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK
- Department of Paediatric Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
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Pané A, Milad C, Santana-Domínguez M, Baños N, Borras-Novell C, Espinosa G, Magnano L, Nomdedeu M, Moreno-Lozano PJ, Cofan F, Placeres M, Fernández RM, García-Villoria J, Garrabou G, Vinagre I, Tanner LM, Montserrat-Carbonell C, Forga-Visa MDT. Lysinuric Protein Intolerance and Its Nutritional and Multisystemic Challenges in Pregnancy: A Case Report and Literature Review. J Clin Med 2023; 12:6405. [PMID: 37835050 PMCID: PMC10573933 DOI: 10.3390/jcm12196405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/01/2023] [Accepted: 10/07/2023] [Indexed: 10/15/2023] Open
Abstract
Lysinuric protein intolerance (LPI) is a rare inborn error of metabolism (IEM), classified as an inherited aminoaciduria, caused by mutations in the SLC7A7 gene, leading to a defective cationic amino acid transport. The metabolic adaptations to the demands of pregnancy and delivery cause significant physiological stress, so those patients affected by IEM are at greater risk of decompensation. A 28-year-old woman with LPI had experienced 3 early miscarriages. While pregnancy was finally achieved, diverse nutritional and medical challenges emerged (food aversion, intrauterine growth restriction, bleeding risk, and preeclampsia suspicion), which put both the mother and the fetus at risk. Moreover, the patient requested a natural childbirth (epidural-free, delayed cord clamping). Although the existence of multiple safety concerns rejected this approach at first, the application of novel strategies made a successful delivery possible. This case reinforces that the woman's wish for a non-medicated, low-intervention natural birth should not be automatically discouraged because of an underlying complex metabolic condition. Achieving a successful pregnancy is conceivable thanks to the cooperation of interdisciplinary teams, but it is still important to consider the risks beforehand in order to be prepared for possible additional complications.
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Affiliation(s)
- Adriana Pané
- Endocrinology and Nutrition Department, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Adult Inborn Errors of Metabolism Unit, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Centro de Investigación Biomédica en Red de la Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), 28029 Madrid, Spain
| | - Camila Milad
- Endocrinology and Nutrition Department, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
| | - Marta Santana-Domínguez
- Neonatology Department, BCNatal (Barcelona Center for Fetal and Neonatal Medicine), Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
| | - Núria Baños
- Neonatology Department, BCNatal (Barcelona Center for Fetal and Neonatal Medicine), Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Fundació Clínic per la Recerca Biomèdica (FCR), Institut d’Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Cristina Borras-Novell
- Neonatology Department, BCNatal (Barcelona Center for Fetal and Neonatal Medicine), Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
| | - Gerard Espinosa
- Fundació Clínic per la Recerca Biomèdica (FCR), Institut d’Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), 08036 Barcelona, Spain
- Autoimmune Diseases Unit, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
| | - Laura Magnano
- Fundació Clínic per la Recerca Biomèdica (FCR), Institut d’Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), 08036 Barcelona, Spain
- Department of Hematology, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
| | - Meritxell Nomdedeu
- Department of Hematology, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
| | - Pedro Juan Moreno-Lozano
- Adult Inborn Errors of Metabolism Unit, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Internal Medicine Department, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Asociación Española para el Estudio de los Errores Congénitos del Metabolismo (AECOM), 28221 Majadahonda, Spain
| | - Frederic Cofan
- Renal Transplantation and Nephrology Department, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
| | - Mercè Placeres
- Adult Inborn Errors of Metabolism Unit, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Pharmacy Department, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
| | - Rosa Maria Fernández
- Biochemistry and Molecular Genetics Department, Biomedical Diagnostic Center, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
| | - Judit García-Villoria
- Adult Inborn Errors of Metabolism Unit, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Asociación Española para el Estudio de los Errores Congénitos del Metabolismo (AECOM), 28221 Majadahonda, Spain
- Biochemistry and Molecular Genetics Department, Biomedical Diagnostic Center, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III (ISCIII), 28029 Madrid, Spain
| | - Glòria Garrabou
- Adult Inborn Errors of Metabolism Unit, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Biochemistry and Molecular Genetics Department, Biomedical Diagnostic Center, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III (ISCIII), 28029 Madrid, Spain
- Inherited Metabolic Diseases and Muscle Disorders Laboratory, FCRB-IDIBAPS and Faculty of Medicine and Heath Sciences, University of Barcelona, 08036 Barcelona, Spain
| | - Irene Vinagre
- Endocrinology and Nutrition Department, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Fundació Clínic per la Recerca Biomèdica (FCR), Institut d’Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Laura M. Tanner
- Fetomaternal Medical Center and Department of Clinical Genetics, Helsinki University Hospital, Department of Medical and Clinical Genetics, University of Helsinki, 00251 Helsinki, Finland
| | - Cristina Montserrat-Carbonell
- Endocrinology and Nutrition Department, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Adult Inborn Errors of Metabolism Unit, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Asociación Española para el Estudio de los Errores Congénitos del Metabolismo (AECOM), 28221 Majadahonda, Spain
| | - Maria de Talló Forga-Visa
- Endocrinology and Nutrition Department, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Adult Inborn Errors of Metabolism Unit, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Asociación Española para el Estudio de los Errores Congénitos del Metabolismo (AECOM), 28221 Majadahonda, Spain
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Pinto SG, Martins Lima P, Dias J. Anesthetic Management of the Surgical Correction of Idiopathic Scoliosis in a Teenager With Ornithine Transcarbamalyse Deficiency. Cureus 2023; 15:e45393. [PMID: 37854728 PMCID: PMC10580218 DOI: 10.7759/cureus.45393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2023] [Indexed: 10/20/2023] Open
Abstract
Ornithine transcarbamylase (OTC) deficiency is the most common genetic disorder of the urea cycle. These disorders are characterized by an inability to metabolize ammonia into urea, leading to hyperammonemia with variable physiological consequences and presenting important anesthetic challenges, especially the perioperative prevention of hyperammonemia and management of its consequences, should it occur. Idiopathic scoliosis (IS) is the most common spinal deformity requiring surgical treatment. This paper presents the case of a 16-year-old female with OTC deficiency who underwent spinal fusion for IS. The chosen anesthetic strategy was combined anesthesia with total intravenous general anesthesia using target-controlled infusion pumps, an erector spinae plane block (ESPB), and a multi-pronged approach to ensure metabolic control while avoiding hyperammonemia. The existing literature regarding major surgery in patients with OTC deficiency is sparse, and this paper provides one of the first case reports of a scoliosis correction surgery, as well as one of the first descriptions of prolonged propofol infusion and locoregional anesthesia with an erector spinae plane block in this context.
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Affiliation(s)
- Sérgio G Pinto
- Anesthesiology, Centro Hospitalar Universitário São João, Porto, PRT
| | | | - José Dias
- Anesthesiology, Centro Hospitalar Universitário São João, Porto, PRT
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7
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Ibrahim MS, Gold JI, Woodall A, Yilmaz BS, Gissen P, Stepien KM. Diagnostic and Management Issues in Patients with Late-Onset Ornithine Transcarbamylase Deficiency. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1368. [PMID: 37628367 PMCID: PMC10453542 DOI: 10.3390/children10081368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 07/24/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023]
Abstract
Ornithine transcarbamylase deficiency (OTCD) is the most common inherited disorder of the urea cycle and, in general, is transmitted as an X-linked recessive trait. Defects in the OTC gene cause an impairment in ureagenesis, resulting in hyperammonemia, which is a direct cause of brain damage and death. Patients with late-onset OTCD can develop symptoms from infancy to later childhood, adolescence or adulthood. Clinical manifestations of adults with OTCD vary in acuity. Clinical symptoms can be aggravated by metabolic stressors or the presence of a catabolic state, or due to increased demands upon the urea. A prompt diagnosis and relevant biochemical and genetic investigations allow the rapid introduction of the right treatment and prevent long-term complications and mortality. This narrative review outlines challenges in diagnosing and managing patients with late-onset OTCD.
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Affiliation(s)
- Majitha Seyed Ibrahim
- Department of Chemical Pathology, Teaching Hospital Batticaloa, Batticaloa 30000, Sri Lanka
| | - Jessica I. Gold
- Division of Human Genetics, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Alison Woodall
- Adult Inherited Metabolic Diseases, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
| | - Berna Seker Yilmaz
- Great Ormond Street Institute of Child Health, University College London, London WC1E 6BT, UK
| | - Paul Gissen
- Great Ormond Street Institute of Child Health, University College London, London WC1E 6BT, UK
- Department of Paediatric Metabolic Medicine, Great Ormond Street Hospital for Children NHS Trust, London WC1N 3JH, UK
- National Institute of Health Research, Great Ormond Street Biomedical Research Centre, London WC1N 1EH, UK
| | - Karolina M. Stepien
- Adult Inherited Metabolic Diseases, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
- Division of Cardiovascular Sciences, University of Manchester, Manchester M13 9PL, UK
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8
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Shakerdi L, Ryan A. Drug-induced hyperammonaemia. J Clin Pathol 2023:jcp-2022-208644. [PMID: 37164630 DOI: 10.1136/jcp-2022-208644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 04/28/2023] [Indexed: 05/12/2023]
Abstract
Hyperammonaemia (HA) as a consequence of numerous primary or secondary causes, gives rise to clinical manifestations due to its toxic effects on the brain. The neurological consequences broadly reflect the ammonia level, duration and age, with paediatric patients being more susceptible. Drug-induced HA may arise due to either decreased ammonia elimination or increased production. This is associated most frequently with use of valproate and presents a dilemma between ongoing therapeutic need, toxicity and the possibility of an alternative cause. As there is no specific test for drug-induced HA, prompt discussion with a metabolic physician is recommended, as the neurotoxic effects are time-dependent. Specific guidelines for managing drug-induced HA have yet to be published and hence the treatment approach outlined in this review reflects that outlined in relevant urea cycle disorder guidelines.
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Affiliation(s)
- Loai Shakerdi
- National Centre for Inherited Metabolic Disorders, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Aidan Ryan
- Chemical Pathology, Cork University Hospital Biochemistry Laboratory, Cork, Ireland
- Pathology, University College Cork College of Medicine and Health, Cork, Ireland
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9
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Piñar-Gutiérrez A, Dios Fuentes E, Benítez-Ávila R, de Ana-Lobato L, Bueno-Delgado MDA, Soto-Moreno A, Venegas-Moreno E. Maternal-fetal outcomes of pregnancies in women treated at an inborn errors of metabolism unit. ENDOCRINOL DIAB NUTR 2023; 70:98-106. [PMID: 36870805 DOI: 10.1016/j.endien.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/08/2022] [Indexed: 03/06/2023]
Abstract
INTRODUCTION Intermediate Inborn Errors of Metabolism (IEM) are a group of inherited diseases that include phenylketonuria (PKU), tyrosinemia II (TSII), organic acidaemias and ornithine transcarbamylase deficiency (OTCD), among others. They are increasingly more common in adults due to improved management. This has allowed more affected women to consider having children with good prospects. However, pregnancy may worsen metabolic control and/or increase maternal-fetal complications. The objective is to analyse the characteristics and outcomes of pregnancies of our patients with IEM. METHODS Retrospective descriptive study. Pregnancies of women with IEM attended to at the adult IEM referral unit of the Hospital Universitario Virgen del Rocío were included. The qualitative variables were described as n(%) and the quantitative as P50 (P25-P75). RESULTS 24 pregnancies were recorded: 12 newborns were healthy, 1 inherited their mother's disease, 2 had maternal phenylketonuria syndrome, 1 was stillborn (gestational week 31 + 5), 5 were spontaneous abortions and 3 were voluntarily terminated. The gestations were divided into metabolically controlled and uncontrolled. CONCLUSIONS Pregnancy planning and multidisciplinary management through to postpartum is essential to ensure maternal and fetal health. The basis of treatment in PKU and TSII is a strict protein-limited diet. Events that increase protein catabolism in organic acidaemias and DOTC should be avoided. Further investigation of pregnancy outcomes in women with IEM is needed.
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Affiliation(s)
- Ana Piñar-Gutiérrez
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain.
| | - Elena Dios Fuentes
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Rosa Benítez-Ávila
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Laura de Ana-Lobato
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - María Del Amor Bueno-Delgado
- Unidad de Metabolopatías, Unidad de Gestión Clínica de Pediatría, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Alfonso Soto-Moreno
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Eva Venegas-Moreno
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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10
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Hyperammonemia in a pregnant woman with citrullinemia type I: a case report and literature review. BMC Pregnancy Childbirth 2022; 22:950. [PMID: 36536326 PMCID: PMC9762101 DOI: 10.1186/s12884-022-05298-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 12/09/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Citrullinemia type I (CTLN1) is a rare urea cycle disorder (UCD) with few adult cases described so far. Diagnosis of late-onset CTLN1 is difficult, and delayed treatment may increase the risk of severe hyperammonemia. Pregnancy is an important risk factor for women with CTLN1. However, the clinical manifestations of CTLN1 in a pregnant woman may be mistaken for pregnancy side effects and ultimately delay a timely diagnosis. CASE PRESENTATION A 34-year-old woman developed vomiting and disturbance of consciousness after 12 weeks of gestation. A blood test showed hyperammonemia (454 μg/dL) with normal liver function tests. She fell into a deep coma, and her serum ammonia level increased to 800 μg/dL. Continuous renal replacement therapy (CRRT) was administered as a diagnostic treatment for UCD and serum ammonia. This patient's case was complicated by co-infection; her dependents decided to withdraw life support and the patient died. She was diagnosed with CTLN1 by analyses of plasma amino acids, urinary orotic acid, and second-generation gene sequencing. DISCUSSION AND CONCLUSION When a patient displays symptoms of emesis and disturbance of consciousness in early pregnancy, blood ammonia should be monitored, and UCD should be considered, particularly for patients with hyperammonemia in the absence of severe liver function abnormalities.
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11
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Feigenbaum A. Challenges of managing ornithine transcarbamylase deficiency in female heterozygotes. Mol Genet Metab Rep 2022; 33:100941. [PMID: 36620389 PMCID: PMC9817477 DOI: 10.1016/j.ymgmr.2022.100941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Urea cycle disorders (UCDs) are a group of rare inherited metabolic conditions caused by enzyme deficiency within the hepatic ammonia detoxification pathway. Ornithine transcarbamylase (OTC) deficiency, the most frequently occurring UCD, is an X-linked condition known to yield a vastly heterogeneous phenotype, with variable onset and presentation across the lifespan. Here, we introduce a series of 4 original cases, published as part of this special supplement, that illustrate learnings for the care of heterozygous females with OTC deficiency, including challenges with diagnosis, potential triggers of hyperammonemia, cognitive effects, and approaches to disease management, including peripartum care.
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Affiliation(s)
- Annette Feigenbaum
- Department of Pediatrics, Division of Genetics, Rady Children's Hospital-San Diego, USA,University of California, San Diego, USA,Corresponding author at: Rady Children's Hospital-San Diego, Division of Genetics, 3020 Children's Way #5031, San Diego, CA 92123, USA.
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12
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Piñar-Gutiérrez A, Dios Fuentes E, Benítez-Ávila R, de Ana-Lobato L, Bueno-Delgado MDA, Soto-Moreno A, Venegas-Moreno E. Resultados materno-fetales de las gestaciones de mujeres atendidas en una unidad de errores innatos del metabolismo. ENDOCRINOL DIAB NUTR 2022. [DOI: 10.1016/j.endinu.2022.09.008] [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: 11/28/2022]
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13
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Iijima H, Kubota M. A simple screening method for heterozygous female patients with ornithine transcarbamylase deficiency. Mol Genet Metab 2022; 137:301-307. [PMID: 36252454 DOI: 10.1016/j.ymgme.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/08/2022] [Accepted: 10/08/2022] [Indexed: 11/24/2022]
Abstract
Ornithine transcarbamylase deficiency (OTCD), caused by X-linked OTC mutations, is characterized by life-threatening hyperammonemia. Heterozygous female patients are often asymptomatic and usually have milder disease than affected male patients, but can have higher morbidity and mortality rates if the disease progresses prior to diagnosis. Our purpose was to establish a screening method for female heterozygotes with OTCD. We retrospectively identified female patients who underwent plasma amino acid analysis at the National Center for Child Health and Development, using data from electronic medical records from March 2002 to September 2021. We extracted patient age, medical history, and biochemical data, including plasma amino acid levels. Patients were categorized into several groups according to their underlying diseases; those with underlying diseases that could potentially affect plasma amino acid levels, such as mitochondrial disease or short bowel syndrome, were excluded, except for untreated OTCD. Biochemical values were compared between OTCD patients and others using the Mann-Whitney U test. The receiver operator characteristic analysis was performed to assess the diagnostic capability for detecting OTCD in each subject. For patients with multiple test data, the most recent of the measurement dates was used in the analysis. The data sets of 976 patients were included. There were significant differences in values of glutamine, citrulline, arginine, and ammonia, but the diagnostic capacity of each alone was inadequate. By contrast, the (glutamine + glycine)/(citrulline + arginine) ratio was appropriate for discriminating heterozygous female patients with OTCD, with a sensitivity of 100% and specificity of 98.6% when the cutoff level was 15.8; the AUC for this discrimination was 0.996 (95% confidence interval, 0.992 to 1.000). These findings could help identify heterozygous female patients with OTCD before the onset of clinical disease.
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Affiliation(s)
- Hiroyuki Iijima
- Department of General Pediatrics and Interdisciplinary Medicine, National Center for Child Health and Development, Tokyo, Japan.
| | - Mitsuru Kubota
- Department of General Pediatrics and Interdisciplinary Medicine, National Center for Child Health and Development, Tokyo, Japan
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14
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Seker Yilmaz B, Baruteau J, Arslan N, Aydin HI, Barth M, Bozaci AE, Brassier A, Canda E, Cano A, Chronopoulou E, Connolly GM, Damaj L, Dawson C, Dobbelaere D, Douillard C, Eminoglu FT, Erdol S, Ersoy M, Fang S, Feillet F, Gokcay G, Goksoy E, Gorce M, Inci A, Kadioglu B, Kardas F, Kasapkara CS, Kilic Yildirim G, Kor D, Kose M, Marelli C, Mundy H, O’Sullivan S, Ozturk Hismi B, Ramachandran R, Roubertie A, Sanlilar M, Schiff M, Sreekantam S, Stepien KM, Uzun Unal O, Yildiz Y, Zubarioglu T, Gissen P. Three-Country Snapshot of Ornithine Transcarbamylase Deficiency. Life (Basel) 2022; 12:1721. [PMID: 36362876 PMCID: PMC9695856 DOI: 10.3390/life12111721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 11/16/2022] Open
Abstract
X-linked ornithine transcarbamylase deficiency (OTCD) is the most common urea cycle defect. The disease severity ranges from asymptomatic carrier state to severe neonatal presentation with hyperammonaemic encephalopathy. We audited the diagnosis and management of OTCD, using an online 12-question-survey that was sent to 75 metabolic centres in Turkey, France and the UK. Thirty-nine centres responded and 495 patients were reported in total. A total of 208 French patients were reported, including 71 (34%) males, 86 (41%) symptomatic and 51 (25%) asymptomatic females. Eighty-five Turkish patients included 32 (38%) males, 39 (46%) symptomatic and 14 (16%) asymptomatic females. Out of the 202 UK patients, 66 (33%) were male, 83 (41%) asymptomatic and 53 (26%) symptomatic females. A total of 19%, 12% and 7% of the patients presented with a neonatal-onset phenotype in France, Turkey and the UK, respectively. Vomiting, altered mental status and encephalopathy were the most common initial symptoms in all three countries. While 69% in France and 79% in Turkey were receiving protein restriction, 42% were on a protein-restricted diet in the UK. A total of 76%, 47% and 33% of patients were treated with ammonia scavengers in Turkey, France and the UK, respectively. The findings of our audit emphasize the differences and similarities in manifestations and management practices in three countries.
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Affiliation(s)
- Berna Seker Yilmaz
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK
| | - Julien Baruteau
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK
- National Institute of Health Research Great Ormond Street Biomedical Research Centre, London WC1N 1EH, UK
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - Nur Arslan
- Paediatric Metabolic Medicine Department, Dokuz Eylul University Faculty of Medicine, Izmir 35340, Turkey
| | - Halil Ibrahim Aydin
- Paediatric Metabolic Medicine Department, Baskent University Faculty of Medicine, Ankara 06490, Turkey
| | - Magalie Barth
- Centre de Référence des Maladies Héréditaires du Métabolisme, CHU Angers, 4 rue Larrey, CEDEX 9, 49933 Angers, France
| | - Ayse Ergul Bozaci
- Paediatric Metabolic Medicine Department, Diyarbakir Children’s Hospital, Diyarbakir 21100, Turkey
| | - Anais Brassier
- Reference Center for Inborn Errors of Metabolism, Necker University Hospital, APHP and University of Paris Cité, 75015 Paris, France
| | - Ebru Canda
- Paediatric Metabolic Medicine Department, Ege University Faculty of Medicine, Izmir 35100, Turkey
| | - Aline Cano
- Reference Center of Inherited Metabolic Disorders, Timone Enfants Hospital, 264 rue Saint-Pierre, 13005 Marseille, France
| | - Efstathia Chronopoulou
- Department of Inherited Metabolic Disease, Division of Women’s and Children’s Services, University Hospitals Bristol NHS Foundation Trust, Bristol BS1 3NU, UK
| | | | - Lena Damaj
- Centre de Compétence Maladies Héréditaires du Métabolisme, CHU Hôpital Sud, CEDEX 2, 35203 Rennes, France
| | - Charlotte Dawson
- Metabolic Medicine Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK
| | - Dries Dobbelaere
- Medical Reference Center for Inherited Metabolic Diseases, Jeanne de Flandre University Hospital and RADEME Research Team for Rare Metabolic and Developmental Diseases, EA 7364 CHRU Lille, 59000 Lille, France
| | - Claire Douillard
- Medical Reference Center for Inherited Metabolic Diseases, Jeanne de Flandre University Hospital and RADEME Research Team for Rare Metabolic and Developmental Diseases, EA 7364 CHRU Lille, 59000 Lille, France
| | - Fatma Tuba Eminoglu
- Paediatric Metabolic Medicine Department, Ankara University Faculty of Medicine, Ankara 06080, Turkey
| | - Sahin Erdol
- Paediatric Metabolic Medicine Department, Uludag University Faculty of Medicine, Bursa 16059, Turkey
| | - Melike Ersoy
- Paediatric Metabolic Medicine Department, Dr Sadi Konuk Reseach & Training Hospital, Istanbul 34450, Turkey
| | - Sherry Fang
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - François Feillet
- Centre de Référence des Maladies Métaboliques de Nancy, CHU Brabois Enfants, 5 Rue du Morvan, 54500 Vandœuvre-lès-Nancy, France
| | - Gulden Gokcay
- Paediatric Metabolic Medicine Department, Istanbul University Istanbul Faculty of Medicine, Istanbul 34093, Turkey
| | - Emine Goksoy
- Paediatric Metabolic Medicine Department, Cengiz Gokcek Children’s Hospital, Gaziantep 27010, Turkey
| | - Magali Gorce
- Centre de Référence des Maladies Rares du Métabolisme, Hôpital des Enfants—CHU Toulouse, 330 Avenue de Grande-Bretagne, CEDEX 9, 31059 Toulouse, France
| | - Asli Inci
- Paediatric Metabolic Medicine Department, Gazi University Faculty of Medicine, Ankara 06500, Turkey
| | - Banu Kadioglu
- Paediatric Metabolic Medicine Department, Konya City Hospital, Konya 42020, Turkey
| | - Fatih Kardas
- Paediatric Metabolic Medicine Department, Erciyes University Faculty of Medicine, Kayseri 38030, Turkey
| | - Cigdem Seher Kasapkara
- Paediatric Metabolic Medicine Department, Ankara Yildirim Beyazit University Faculty of Medicine, Ankara 06800, Turkey
| | - Gonca Kilic Yildirim
- Paediatric Metabolic Medicine Department, Osmangazi University Faculty of Medicine, Eskisehir 26480, Turkey
| | - Deniz Kor
- Paediatric Metabolic Medicine Department, Cukurova University Faculty of Medicine, Adana 01250, Turkey
| | - Melis Kose
- Paediatric Metabolic Medicine Department, Faculty of Medicine, Izmir Katip Celebi University, Izmir 35620, Turkey
| | - Cecilia Marelli
- MMDN, University Montpellier, EPHE, INSERM, 34090 Montpellier, France
- Expert Center for Metabolic and Neurogenetic Diseases, Centre Hospitalier Universitaire (CHU), 34090 Montpellier, France
| | - Helen Mundy
- Evelina Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
| | | | - Burcu Ozturk Hismi
- Paediatric Metabolic Medicine Department, Marmara University Faculty of Medicine, Istanbul 34854, Turkey
| | | | - Agathe Roubertie
- MMDN, University Montpellier, EPHE, INSERM, 34090 Montpellier, France
- Expert Center for Metabolic and Neurogenetic Diseases, Centre Hospitalier Universitaire (CHU), 34090 Montpellier, France
| | - Mehtap Sanlilar
- Paediatric Metabolic Medicine Department, Antalya Training and Research Hospital, Antalya 07100, Turkey
| | - Manuel Schiff
- Reference Center for Inborn Errors of Metabolism, Necker University Hospital, APHP and University of Paris Cité, 75015 Paris, France
| | - Srividya Sreekantam
- Birmingham Women’s and Children’s Hospital NHS Foundation Trust, Birmingham B4 6NH, UK
| | - Karolina M. Stepien
- Adult Inherited Metabolic Diseases, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK
| | - Ozlem Uzun Unal
- Paediatric Metabolic Medicine Department, Kocaeli University Faculty of Medicine, Kocaeli 41380, Turkey
| | - Yilmaz Yildiz
- Paediatric Metabolic Medicine Department, Hacettepe University Faculty of Medicine, Ankara 06230, Turkey
| | - Tanyel Zubarioglu
- Paediatric Metabolic Medicine Department, Istanbul University-Cerrahpasa Faculty of Medicine, Istanbul 34096, Turkey
| | - Paul Gissen
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK
- National Institute of Health Research Great Ormond Street Biomedical Research Centre, London WC1N 1EH, UK
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
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15
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Fátima Lopes F, Sitta A, de Moura Coelho D, Schmitt Ribas G, Lamberty Faverzani J, Gomes Dos Reis B, Wajner M, Vargas CR. Clinical findings of patients with hyperammonemia affected by urea cycle disorders with hepatic encephalopathy. Int J Dev Neurosci 2022; 82:772-788. [PMID: 36129623 DOI: 10.1002/jdn.10229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/21/2022] [Accepted: 09/15/2022] [Indexed: 11/10/2022] Open
Abstract
Urea Cycle Disorders (UCD) are a group of genetic diseases caused by deficiencies in the enzymes and transporters involved in the urea cycle. The impairment of the cycle results in ammonia accumulation, leading to neurological dysfunctions and poor outcomes to affected patients. The aim of this study is to investigate and describe UCD patients principal clinical and biochemical presentations to support professionals on urgent diagnosis and quick management, aiming better outcomes for patients. We explored medical records of thirty patients diagnosed in a referral center from Brazil to delineate UCD clinical and biochemical profile. Patients demonstrated a range of signs and symptoms, such as altered levels of consciousness, acute encephalopathy, seizures, progressive loss of appetite, vomiting, coma, and respiratory distress, in most cases combined with high levels of ammonia, which is an immediate biomarker, leading to an UCD suspicion. The most prevalent UCD detected were ornithine transcarbamylase deficiency (11), followed by citrullinemia type I (10), hyperargininemia (5), carbamoyl phosphate synthase 1 deficiency (2) and argininosuccinic aciduria (2). Clinical symptoms were highly severe, being the majority developmental and neurological disabilities, with 20% of death rate. Laboratory analysis revealed high levels of ammonia (mean ± SD: 860 ± 470 μmol/L; reference value: ≤ 80 μmol/L), hypoglycemia, metabolic acidosis, and high excretion of orotic acid in the urine (except in CPS1 deficiency). We emphasize the need of urgent identification of UCD clinical and biochemical conditions, and immediate measurement of ammonia, to enable the correct diagnosis and increase the chances of patients survival, minimizing neurological and psychomotor damage caused by hepatic encephalopathy.
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Affiliation(s)
- Franciele Fátima Lopes
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Angela Sitta
- Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | | | | | - Jéssica Lamberty Faverzani
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Bianca Gomes Dos Reis
- Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Moacir Wajner
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Carmen Regla Vargas
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
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16
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A complex case of delayed diagnosis of ornithine transcarbamylase deficiency in an adult patient with multiple comorbidities. Mol Genet Metab Rep 2022; 33:100916. [PMID: 36620385 PMCID: PMC9817481 DOI: 10.1016/j.ymgmr.2022.100916] [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: 05/13/2022] [Revised: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 01/11/2023] Open
Abstract
We report the case of a medically complex African American adult female with ornithine transcarbamylase (OTC) deficiency diagnosed after lifelong protein aversion and new onset of chronic vomiting and abdominal pain with intermittent lethargy and confusion. Symptomatology was crucial to diagnosis as genetic testing did not identify any pathogenic variants in OTC; however, the patient's diagnosis was delayed despite her having longstanding symptoms of a urea cycle disorder (UCD). Her symptoms improved after treatment with a modified protein-restricted diet, long-term nitrogen-scavenger therapy, and supplemental L-citrulline. Adherence to her UCD management regimen remained a challenge due to her underlying frailty and other medical conditions, which included primary renal impairment (further exasperated by type 2 diabetes mellitus) and decreased left-ventricular function. She passed away 3 years after her OTC deficiency diagnosis due to complications of congestive heart failure. Her OTC deficiency did not have a major impact on her final illness, and appropriate OTC deficiency management was provided until the decision was made to withdraw medical care.
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Key Words
- ALT, alanine aminotransferase
- AST, aspartate aminotransferase
- CT, computed tomography
- Comorbid conditions
- D20W, dextrose 20% in water
- ED, emergency department
- GPB, glycerol phenylbutyrate
- Hepatic encephalopathy
- IBW, ideal body weight
- IV, intravenous
- Late onset
- NAFLD, nonalcoholic fatty liver disease
- NG, nasogastric
- OTC, ornithine transcarbamylase
- Ornithine transcarbamylase deficiency
- UCD, urea cycle disorder
- Urea cycle disorder
- X-linked inheritance
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17
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Mütze U, Mengler K, Boy N, Gleich F, Opladen T, Garbade SF, Kölker S. How longitudinal observational studies can guide screening strategy for rare diseases. J Inherit Metab Dis 2022; 45:889-901. [PMID: 35488475 DOI: 10.1002/jimd.12508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 11/12/2022]
Abstract
Newborn screening (NBS) is an important secondary prevention program, aiming to shift the paradigm of medicine to the pre-clinical stage of a disease. Starting more than 50 years ago, technical advances, such as tandem mass spectrometry (MS/MS), paved the way to a continuous extension of NBS programs. However, formal evidence of the long-term clinical benefits in large cohorts and cost-effectiveness of extended NBS programs is still scarce. Although published studies confirmed important benefits of NBS programs, it also unraveled a significant number of limitations. These include an incompletely understood natural history and phenotypic diversity of some screened diseases, unreliable early and precise prediction of individual disease severity, uncertainty about case definition, risk stratification, and indication to treat, resulting in a diagnostic and treatment dilemma in individuals with ambiguous screening and confirmatory test results. Interoperable patient registries are multi-purpose tools that could help to close the current knowledge gaps and to inform further optimization of NBS strategy. Standing at the edge of introducing high throughput genetic technologies to NBS programs with the opportunity to massively extend NBS programs and with the risk of aggravating current limitations of NBS programs, it seems overdue to include mandatory long-term follow-up of NBS cohorts into the list of screening principles and to build an international collaborative framework that enables data collection and exchange in a protected environment, integrating the perspectives of patients, families, and the society.
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Affiliation(s)
- Ulrike Mütze
- Division of Child Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Katharina Mengler
- Division of Child Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Nikolas Boy
- Division of Child Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Florian Gleich
- Division of Child Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Opladen
- Division of Child Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Sven F Garbade
- Division of Child Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan Kölker
- Division of Child Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
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Goswami J, Simalti A, mishra A. Citrullinemia, a rare cause of recurring encephalopathy. Med J Armed Forces India 2022; 78:S319-S322. [PMID: 36147420 PMCID: PMC9485739 DOI: 10.1016/j.mjafi.2019.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 12/27/2019] [Indexed: 10/24/2022] Open
Abstract
An infant presented with recurrent episodes of encephalopathy, responding to nonspecific management of sepsis. High index of suspicion helped uncover underlying error of metabolism.
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Affiliation(s)
- J.N. Goswami
- Senior Advisor (Pediatrics) & Pediatric Neurologist, Army Hospital R & R, Delhi Cantt. 110010, India
| | - A.K. Simalti
- Classified Specialist (Pediatrics) & Trained in Pediatric Intensive Care, Army Hospital (R & R), Delhi Cantt. 110010, India
| | - Atul mishra
- Senior Advisor (Radiology) & Intervention Radiologist, Army Hospital (R & R), Delhi Cantt. 110010, India
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19
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Feigenbaum A, Lamale-Smith L, Weinstein L. Considerations for prenatal and postpartum management of a female patient with ornithine transcarbamylase deficiency. Mol Genet Metab Rep 2022; 33:100894. [PMID: 36620386 PMCID: PMC9817480 DOI: 10.1016/j.ymgmr.2022.100894] [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: 05/13/2022] [Revised: 06/27/2022] [Accepted: 06/27/2022] [Indexed: 01/11/2023] Open
Abstract
We report on pregnancy management and outcomes in a 27-year-old female patient with ornithine transcarbamylase (OTC) deficiency, the most common inherited enzyme deficiency in the urea cycle. Our patient was diagnosed during childhood after hyperammonemia associated with surgery and steroid treatment and was well-controlled with nitrogen scavenger treatment, low-protein diet, and L-citrulline supplementation. OTC gene sequencing identified a variant of unknown significance that has more recently been classified as likely pathogenic. Women with OTC deficiency are at increased risk of hyperammonemia during pregnancy and the postpartum period, therefore monthly follow up and laboratory assessments are critical in management decision making. Our patient was maintained on glycerol phenylbutyrate, L-citrulline and essential amino acid supplements, along with restricted protein intake during pregnancy. A multidisciplinary approach with the obstetrics, prenatal genetics, high risk obstetric, and anesthesia teams was also necessary for optimal management during pregnancy, throughout labor and delivery, and during the postpartum period. After successful childbirth and discharge, our patient experienced a hyperammonemic crisis related to poor enteral nutrition, and acute management protocols were implemented to stabilize her. For her newborn son, acute hyperammonemia protocols were on standby, and newborn screening and laboratory testing were expedited to assess his risk. He was healthy and did not experience symptoms of concern. In this case report, we emphasize the importance of close collaboration with maternal-fetal medicine team members during and immediately after pregnancy to ensure successful management of a female patient with OTC deficiency and her newborn.
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Key Words
- BCAA, branched-chain amino acids
- BID, twice daily
- D10, 10% dextrose
- EAA, essential amino acids
- GPB, glycerol phenylbutyrate
- IV, intravenous
- NICU, neonatal intensive care unit
- OTC, ornithine transcarbamylase
- Ornithine transcarbamylase deficiency
- PICC, peripherally inserted central catheter
- PO, per os/orally
- Peripartum management
- Pregnancy
- TID, three times daily
- UCD, urea cycle disorder
- Urea cycle disorder
- X-linked, hyperammonemia
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Affiliation(s)
- Annette Feigenbaum
- Department of Pediatrics and Biochemical Genetics, Rady Children's Hospital-San Diego, University of California San Diego, 3020 Children's Way #5031, San Diego, CA 92123, USA
- Corresponding author at: 3020 Children's Way #5031, San Diego, CA 92123, USA.
| | - Leah Lamale-Smith
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, 9300 Campus Point Drive, #7433, San Diego, CA 92037, USA
| | - Lawrence Weinstein
- Department of Anesthesiology, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
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20
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Benefits of tailored disease management in improving tremor, white matter hyperintensities, and liver enzymes in a child with heterozygous X-linked ornithine transcarbamylase deficiency. Mol Genet Metab Rep 2022; 33:100891. [PMID: 36620387 PMCID: PMC9817482 DOI: 10.1016/j.ymgmr.2022.100891] [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: 05/13/2022] [Revised: 06/23/2022] [Accepted: 06/24/2022] [Indexed: 01/11/2023] Open
Abstract
We report the case of a 19-month-old girl with late-onset ornithine transcarbamylase (OTC) deficiency initially referred to gastroenterology for intermittent vomiting lasting a year and abnormal liver enzymes (AST 730 U/L [reference range 26-55 U/L]; ALT 1213 U/L [reference range 11-30 U/L]) without hepatomegaly. While the patient was hospitalized for liver biopsy, intermittent tremors of the upper extremities with varying severity were noted. The patient was presumed to have hyperammonemia secondary to acute liver failure and was discharged after 5 days; follow-up monitoring led to readmission 7 days later. A brain MRI showed nonspecific bilateral pericallosal and bifrontal white matter FLAIR hyperintensities. These findings raised suspicion for a metabolic disease and prompted a genetics consultation. After inconclusive biochemical testing and worsening clinical status, rapid whole genome sequencing results were obtained identifying a novel, de novo, likely pathogenic, variant c.608C > T (p.Ser203Phe) in the OTC gene. The patient was promptly started on an oral nitrogen scavenger, citrulline supplementation, and protein restriction. Ammonia and glutamine levels normalized within 1 month of treatment and have stayed within the goal ranges with continued tailoring of treatment. Her parents noted resolution of vomiting and improved mood stability. Liver enzymes normalized after 2 months of treatment. The tremor, identified as asterixis, improved and a repeat brain MRI 3 months after the initial imaging showed near-complete resolution of previous white matter hyperintensities.
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Key Words
- ALT, alanine transaminase
- AST, aspartate aminotransferase
- Asterixis
- BASC-3, Behavior Assessment System for Children
- BCAA, branched-chain amino acid
- FLAIR, fluid-attenuated inversion recovery
- GGT, gamma-glutamyl transferase
- Late onset
- MRI, magnetic resonance imaging
- MRS, magnetic resonance spectroscopy
- Manifesting heterozygote
- OTC, ornithine transcarbamylase
- Ornithine transcarbamylase deficiency
- PT, prothrombin time
- Partial onset
- TID, 3 times a day
- UCD, urea cycle disorder
- Urea cycle disorder
- WPPSI-IV, Wechsler Preschool and Primary Scale of Intelligence
- X linked
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21
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Exploring the Barriers and Motivators to Dietary Adherence among Caregivers of Children with Disorders of Amino Acid Metabolism (AAMDs): A Qualitative Study. Nutrients 2022; 14:nu14122535. [PMID: 35745265 PMCID: PMC9228574 DOI: 10.3390/nu14122535] [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: 05/16/2022] [Revised: 06/12/2022] [Accepted: 06/15/2022] [Indexed: 11/20/2022] Open
Abstract
Dietary intervention is generally accepted as the mainstay of treatment for patients with disorders of amino acid metabolism (AAMDs). However, dietary adherence to a low-protein diet is always reported as a common challenge among these patients. This study explored the perception of barriers and motivators to dietary adherence among caregivers of AAMD patients in Malaysia. Twenty caregivers of children with AAMDs receiving ongoing treatment at the genetic clinic participated in an online focus group discussion from November to December 2021. Findings showed a total of five interrelated main themes identified from focus group discussion (FGD) exploring parents’ experiences related to the management of their child’s daily diet. The barriers to dietary adherence were burden of dietary treatment, diet and dietary behavior, parenting challenges, limited knowledge related to dietary treatment, and challenges in healthcare system delivery. Key factors facilitating good dietary adherence include good knowledge of dietary treatment, parental coping strategies, social coping, and dietary behavior. In conclusion, despite the existence of several barriers to the implementation of dietary treatment, caregivers managed to use a wide range of coping strategies to overcome some, if not all, of the challenges. The important next step is to develop, in conjunction with multidisciplinary healthcare professionals, feasible implementation strategies that could address these barriers and at the same time improve the quality of life of caregivers.
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22
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Tumienė B, del Toro Riera M, Grikiniene J, Samaitiene-Aleknienė R, Praninskienė R, Monavari AA, Sykut-Cegielska J. Multidisciplinary Care of Patients with Inherited Metabolic Diseases and Epilepsy: Current Perspectives. J Multidiscip Healthc 2022; 15:553-566. [PMID: 35387391 PMCID: PMC8977775 DOI: 10.2147/jmdh.s251863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 03/17/2022] [Indexed: 11/25/2022] Open
Abstract
More than 650 inherited metabolic diseases may present with epilepsy or seizures. These diseases are often multisystem, life-long and induce complex needs of patients and families. Multidisciplinary care involves all stages of disease management: diagnostics, specific or symptomatic, acute and chronic treatments, and integrated care that takes into account not only medical, but also manifold psychosocial, educational, vocational and other needs of patients and their caregivers. Care coordination is indispensable to ensure smooth transitions of care across life and disease stages, including management of emergencies, transition from pediatric to adult services and palliative care. Care pathways are highly diverse and have to find the right balance between highly specialized and locally provided services. While multidisciplinary teams consist of many professionals, a named supervising physician in a highly specialized healthcare setting and a care coordinator are highly important. As the greatest burden of care always falls onto the shoulders of patients and/or families, patient empowerment should be a part of every care pathway and include provision of required information, involvement into common decision-making, patient’s and family’s education, support for self-management, liaison with peer support groups and emotional/ psychological support. Due to the rarity and complexity of these diseases, sufficient expertise may not be available in a national healthcare system and cross-border services (virtual or physical) in the recently developed European Reference Networks should be ensured through the proper organization of referral systems in each EU and EEA country. Finally, digital technologies are particularly important in the provision of services for patients with rare diseases and can significantly increase the availability of highly specialized services and expertise.
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Affiliation(s)
- Birutė Tumienė
- Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Vilnius University Hospital Santaros klinikos, Vilnius, Lithuania
- Correspondence: Birutė Tumienė, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, Santariskiu str. 2, Vilnius, LT-06681, Lithuania, Tel +370 614 45026, Email
| | - Mireia del Toro Riera
- Pediatric Neurology Department, Unit of Hereditary Metabolic Disorders, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Jurgita Grikiniene
- Clinic of Children’s Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Rūta Samaitiene-Aleknienė
- Clinic of Children’s Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Rūta Praninskienė
- Clinic of Children’s Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Ahmad Ardeshir Monavari
- National Centre for Inherited Metabolic Disorders, Children’s Health Ireland at Temple Street Dublin, Dublin, Ireland
- University College Dublin, Dublin, Ireland
| | - Jolanta Sykut-Cegielska
- Department of Inborn Errors of Metabolism and Paediatrics, the Institute of Mother and Child, Warsaw, Poland
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23
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Hyperammonaemic Encephalopathy Caused by Adult-Onset Ornithine Transcarbamylase Deficiency. Brain Sci 2022; 12:brainsci12020231. [PMID: 35203994 PMCID: PMC8870301 DOI: 10.3390/brainsci12020231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 02/01/2023] Open
Abstract
Hyperammonaemic encephalopathy in adults is a rare condition in the absence of liver disease and is associated with a high mortality and risk of permanent neurological deficits. Seldomly, the condition is caused by an inborn error of metabolism in the urea cycle, triggered by an exogenic factor such as gastrointestinal haemorrhage, gastric bypass surgery, starvation, seizures, vigorous exercise, burn injuries, or drugs hampering the elimination of ammonia. Here, we present a fatal case of an unrecognized genetic ornithine transcarbamylase deficiency (OTCD) presenting with a subacute progressive encephalopathy. We review the current literature and discuss the differential diagnosis and treatment options. As swift diagnosis and initiation of treatment is vital, awareness of hyperammonaemic encephalopathy and its possible causes can help improve the prognosis of this condition.
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24
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Donlon E, McGettigan J, Gaffney C, Ahmad MW, Boers P, Treacy E, Chaila E. Late-onset ornithine transcarbamylase deficiency mimicking a focal opercular syndrome. Pract Neurol 2022; 22:224-227. [PMID: 35046116 DOI: 10.1136/practneurol-2021-003196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2021] [Indexed: 12/24/2022]
Abstract
A previously healthy 27-year-old man was brought to hospital after been found late at night confused, agitated and talking incoherently. He represented 12 days later with focal seizures, progressing to anarthria and encephalopathy. MR scan of brain showed diffuse cerebral oedema and his plasma ammonia was >2000 µmol/L (12-55 µmol/L). He developed refractory status epilepticus and subsequently died. Genetic analysis identified an ornithine transcarbamylase (OTC) gene mutation on the X chromosome. We discuss this atypical presentation of OTC deficiency as a rare but treatable cause of hyperammonaemic encephalopathy.
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Affiliation(s)
- Eoghan Donlon
- Department of Neurology, University Hospital Limerick, Dooradoyle, Ireland
| | - Jamie McGettigan
- Department of Neurology, University Hospital Limerick, Dooradoyle, Ireland
| | - Christine Gaffney
- Department of Neurology, University Hospital Limerick, Dooradoyle, Ireland
| | - Marzuki Wan Ahmad
- Department of Neurology, University Hospital Limerick, Dooradoyle, Ireland
| | - Peter Boers
- Department of Neurology, University Hospital Limerick, Dooradoyle, Ireland
| | - Eileen Treacy
- Department of Metabolic Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Elijah Chaila
- Department of Neurology, University Hospital Limerick, Dooradoyle, Ireland
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25
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Wykowski J, Keller C, Kucybala K. Adult-Onset Type 1 Citrullinemia Presenting as Postpartum Acute Liver Failure. Am J Med 2022; 135:e22-e23. [PMID: 34560033 DOI: 10.1016/j.amjmed.2021.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 11/25/2022]
Affiliation(s)
- James Wykowski
- Department of Medicine, University of Washington, Seattle.
| | - Carolyn Keller
- Department of Medicine, University of Washington, Seattle
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26
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Sen K, Whitehead M, Castillo Pinto C, Caldovic L, Gropman A. Fifteen years of urea cycle disorders brain research: Looking back, looking forward. Anal Biochem 2022; 636:114343. [PMID: 34637785 PMCID: PMC8671367 DOI: 10.1016/j.ab.2021.114343] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/13/2021] [Accepted: 08/17/2021] [Indexed: 01/03/2023]
Abstract
Urea cycle disorders (UCD) are inherited diseases resulting from deficiency in one of six enzymes or two carriers that are required to remove ammonia from the body. UCD may be associated with neurological damage encompassing a spectrum from asymptomatic/mild to severe encephalopathy, which results in most cases from Hyperammonemia (HA) and elevation of other neurotoxic intermediates of metabolism. Electroencephalography (EEG), Magnetic resonance imaging (MRI) and Proton Magnetic resonance spectroscopy (MRS) are noninvasive measures of brain function and structure that can be used during HA to guide management and provide prognostic information, in addition to being research tools to understand the pathophysiology of UCD associated brain injury. The Urea Cycle Rare disorders Consortium (UCDC) has been invested in research to understand the immediate and downstream effects of hyperammonemia (HA) on brain using electroencephalogram (EEG) and multimodal brain MRI to establish early patterns of brain injury and to track recovery and prognosis. This review highlights the evolving knowledge about the impact of UCD and HA in particular on neurological injury and recovery and use of EEG and MRI to study and evaluate prognostic factors for risk and recovery. It recognizes the work of others and discusses the UCDC's prior work and future research priorities.
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Affiliation(s)
- Kuntal Sen
- Division of Neurogenetics and Neurodevelopmental Pediatrics, Children's National Hospital, Washington D.C., United States
| | - Matthew Whitehead
- Division of Radiology, Children's National Hospital, Washington D.C., United States
| | | | - Ljubica Caldovic
- Childrens' Research Institute, Children's National Hospital, Washington D.C., United States
| | - Andrea Gropman
- Division of Neurogenetics and Neurodevelopmental Pediatrics, Children's National Hospital, Washington D.C., United States.
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27
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Yeowell G, Burns DS, Fatoye F. The burden of pharmacological treatment on health-related quality of life in people with a urea cycle disorder: a qualitative study. J Patient Rep Outcomes 2021; 5:110. [PMID: 34694515 PMCID: PMC8546029 DOI: 10.1186/s41687-021-00387-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 10/11/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Urea cycle disorders (UCD) are inborn errors of metabolism, typically presenting neonatally. Excess ammonia builds rapidly within the body risking hyperammonemic episodes and potentially death. Long-term management of the condition includes restrictive protein consumption, pharmacological interventions and, in extreme cases, liver transplantation. Pharmacological treatments such as sodium benzoate and sodium phenylbutyrate have proven effective but not without a multitude of negative attributes including poor taste, higher dosage and associated gastrointestinal discomfort that impacts health-related quality of life. Glycerol phenylbutyrate (GPB) has recently become a widely available pharmacological treatment with early reports of improved qualities, including taste and administration method. The following study aims to explore the burden of pharmacological treatment and the effects of the transition to GPB on health-related quality of life in people with a UCD. RESULTS Nine carers of children living with a UCD (mean age = 12.44, SD = 10.26) were interviewed regarding their experiences of pharmacological treatment in relation to their, and their child's, health-related quality of life after transitioning to GPB. Three main themes were identified: psychological health, physical health and social participation. Carers struggled with anxiety surrounding their child's condition and the battle of administering medication. Medication administration was perceived to have improved since the transition to GPB, alleviating distress for both carer and child. Issues involving school were described, ranging from difficulties integrating their child into mainstream schooling and the impact of treatment on participation in school and extracurricular activities. Carers encountered issues sourcing syringes to administer GPB, which induced stress. It could be suggested that some burden had been relieved by the transition to GPB. However, it appeared that difficulties associated with the illness would persist despite treatment, owing to the continuing nature of the condition. CONCLUSIONS Adhering to a strict pharmacological regime caused immense stress for both carers and children, severely impacting on typical social activities such as eating at a restaurant or going on holiday. GPB was perceived to have alleviated some burden in terms of administration given improved characteristics concerning taste and dosage, important characteristics for both carers and children living with UCD. Practitioners should consider these findings when making clinical decisions for children with UCD and the effect of pharmacological treatment on carer's health-related quality of life. Outreach work to facilitate greater understanding of the condition should be conducted with key locations, such as children's schools. This would also help to alleviate carer burden.
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Affiliation(s)
- Gillian Yeowell
- Department of Health Professions, Manchester Metropolitan University, 53 Bonsall Street, Manchester, M15 6GX, UK.
| | - Danielle Stephanie Burns
- Department of Health Professions, Manchester Metropolitan University, 53 Bonsall Street, Manchester, M15 6GX, UK
| | - Francis Fatoye
- Department of Health Professions, Manchester Metropolitan University, 53 Bonsall Street, Manchester, M15 6GX, UK
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28
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Kamusheva M, Milushewa P. Rare disease patients’ needs: an up-to-date analysis and future directions. PHARMACIA 2021. [DOI: 10.3897/pharmacia.68.e73240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The interest to rare diseases has increased in the recent decades. Legislation seeks to facilitate patients’ access to innovative and effective treatment and to define incentives for pharmaceutical and biotechnology companies to develop new medicines for rare diseases.The current review presents the current knowledge and adopted solutions in the field of rare diseases and discusses the future issues and unmet needs that should be resolved for affected patients and their families. Along with the positive trends in the field of rare diseases, there are still issues related to diagnosis and inequal care for some patients groups that should be solved over the next decade. The innovative digital health methods, which have been improved continuously in the recent years, implementation of improved versions of patient-centered policy plans and programs and investment in advanced therapies could move forward the rare diseases to new horizons giving them the opportunity to overcome the main barriers and challenges in the whole journey of the patients – from diagnosis through treatment to follow-up.
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29
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Toquet S, Spodenkiewicz M, Douillard C, Maillot F, Arnoux JB, Damaj L, Odent S, Moreau C, Redonnet-Vernhet I, Mesli S, Servais A, Noel E, Charriere S, Rigalleau V, Lavigne C, Kaphan E, Roubertie A, Besson G, Bigot A, Servettaz A, Mochel F, Garnotel R. Adult-onset diagnosis of urea cycle disorders: Results of a French cohort of 71 patients. J Inherit Metab Dis 2021; 44:1199-1214. [PMID: 34014557 DOI: 10.1002/jimd.12403] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 05/14/2021] [Accepted: 05/18/2021] [Indexed: 12/19/2022]
Abstract
Urea cycle disorders (UCD) are rare diseases that usually affect neonates or young children. During decompensations, hyperammonemia is neurotoxic, leading to severe symptoms and even coma and death if not treated rapidly. The aim was to describe a cohort of patients with adult onset of UCDs in a multicentric, retrospective and descriptive study of French adult patients with a diagnosis after 16 years of age of UCDs due to a deficiency in one of the 6 enzymes (arginase, ASL, ASS, CPS1, NAGS, OTC) or the two transporters (ORNT1 or citrin). Seventy-one patients were included (68% female, 32% male). The diagnosis was made in the context of (a) a metabolic decompensation (42%), (b) family history (55%), or (c) chronic symptoms (3%). The median age at diagnosis was 33 years (range 16-86). Eighty-nine percent of patients were diagnosed with OTC deficiency, 7% CPS1 deficiency, 3% HHH syndrome and 1% argininosuccinic aciduria. For those diagnosed during decompensations (including 23 OTC cases, mostly female), 89% required an admission in intensive care units. Seven deaths were attributed to UCD-6 decompensations and 1 epilepsy secondary to inaugural decompensation. This is the largest cohort of UCDs diagnosed in adulthood, which confirms the triad of neurological, gastrointestinal and psychiatric symptoms during hyperammonemic decompensations. We stress that females with OTC deficiency can be symptomatic. With 10% of deaths in this cohort, UCDs in adults remain a life-threatening condition. Physicians working in adult care must be aware of late-onset presentations given the implications for patients and their families.
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Affiliation(s)
- Ségolène Toquet
- Service de Médecine Interne, Hôpital Robert Debré, CHU Reims, France
| | | | - Claire Douillard
- Service d'Endocrinologie et Métabolismes, Hôpital Claude Huriez, Centre de Référence des Maladies Héréditaires du métabolisme, CHU Lille, France
| | - François Maillot
- Service de Médecine Interne, Hôpital Bretonneau, CHRU de Tours, France
| | - Jean-Baptiste Arnoux
- Centre de Référence des Maladies Héréditaires du Métabolisme, Hôpital Necker-Enfants Malades, CHU Paris, France
| | - Lena Damaj
- Service de Pédiatrie, CHU Hôpital Sud, Rennes, France
| | - Sylvie Odent
- Service de Génétique Clinique, CHU Hôpital Sud, Rennes, France
| | - Caroline Moreau
- Service de Biochimie et Toxicologie, CHU Pontchaillou, Rennes, France
| | | | - Samir Mesli
- Laboratoire de Biochimie, Hôpital Pellegrin, CHU Bordeaux, France
| | - Aude Servais
- Service de Néphrologie adulte, Hôpital Necker-Enfants Malades, CHU Paris, France
| | - Esther Noel
- Service de Médecine Interne, Hôpital Universitaire de Strasbourg, CHRU Strasbourg, France
| | - Sybill Charriere
- Fédération d'endocrinologie, maladies métaboliques, diabète et nutrition, Hôpital Louis Pradel, Centre de Référence des Maladies Héréditaires du Métabolisme, Bron, France
| | | | | | - Elsa Kaphan
- Pôle de Neurosciences Cliniques, CHU Timone, AP-HM, Marseille, France
| | - Agathe Roubertie
- Département de neuropédiatrie, Hôpital Gui de Chauliac, CHU Montpellier, France
| | | | - Adrien Bigot
- Service de Médecine Interne, Hôpital Bretonneau, CHRU de Tours, France
| | - Amélie Servettaz
- Service de Médecine Interne, Hôpital Robert Debré, CHU Reims, France
| | - Fanny Mochel
- Département de génétique, Hôpital Pitié-Salpêtrière, CHU Paris, France
| | - Roselyne Garnotel
- Laboratoire de Biochimie-Pharmacologie-Toxicologie, CHU Reims, France
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30
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Strong A, Gold J, Gold NB, Yudkoff M. Hepatic Manifestations of Urea Cycle Disorders. Clin Liver Dis (Hoboken) 2021; 18:198-203. [PMID: 34745578 PMCID: PMC8549711 DOI: 10.1002/cld.1115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/14/2021] [Accepted: 03/16/2021] [Indexed: 02/04/2023] Open
Abstract
Content available: Author Interview and Audio Recording.
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Affiliation(s)
- Alanna Strong
- Division of Human GeneticsChildren's Hospital of PhiladelphiaPhiladelphiaPA,The Center for Applied GenomicsChildren's Hospital of PhiladelphiaPhiladelphiaPA
| | - Jessica Gold
- Division of Human GeneticsChildren's Hospital of PhiladelphiaPhiladelphiaPA
| | - Nina B. Gold
- Division of Medical Genetics and MetabolismMassachusetts General HospitalBostonMA,Department of PediatricsHarvard Medical SchoolBostonMA
| | - Marc Yudkoff
- Division of Human GeneticsChildren's Hospital of PhiladelphiaPhiladelphiaPA,Department of PediatricsPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
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31
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Mitschek MMM, Vanicek T, Unterholzner J, Kraus C, Weidenauer A, Naderi-Heiden A, Frey R, Silberbauer LR, Gryglewski G, Papageorgiou K, Winkler D, Dold M, Kasper S, Praschak-Rieder N, Bartova L. How to prevent and manage hyperammonemic encephalopathies in valproate therapy. JOURNAL OF AFFECTIVE DISORDERS REPORTS 2021. [DOI: 10.1016/j.jadr.2021.100186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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32
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Liu F, Bao LS, Liang RJ, Zhao XY, Li Z, Du ZF, Lv SG. Identification of rare variants causing urea cycle disorders: A clinical, genetic, and biophysical study. J Cell Mol Med 2021; 25:4099-4109. [PMID: 33611823 PMCID: PMC8051738 DOI: 10.1111/jcmm.16379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 02/01/2021] [Accepted: 02/04/2021] [Indexed: 12/23/2022] Open
Abstract
Urea cycle disorders (UCDs) are a group of rare metabolic conditions characterized by hyperammonemia and a broad spectrum of phenotypic severity. They are caused by the congenital deficiency in the eight biomolecules involved in urea cycle. In the present study, five cases of UCD were recruited and submitted to a series of clinical, biochemical, and genetic analysis with a combination of high throughput techniques. Moreover, in silico analysis was conducted on the identified missense genetic variants. Various clinical and biochemical indications (including profiles of amino acids and urinary orotic acids) of UCD were manifested by the five probands. Sequence analysis revealed nine diagnostic variants, including three novel ones, which caused Argininosuccinic aciduria (ASA) in one case, Carbamoyl phosphate synthetase 1deficiency (CPS1D) in two cases, Ornithine transcarbamylase deficiency (OTCD) in one case, and Citrin deficiency in 1case. Results of in silico biophysical analysis strongly suggested the pathogenicity of each the five missense variants and provided insight into their intramolecular impacts. In conclusion, this study expanded the genetic variation spectrum of UCD, gave solid evidence for counselling to the affected families, and should facilitate the functional study on the proteins in urea cycle.
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Affiliation(s)
- Fang Liu
- Department of Pediatrics, NICU, Bethune International Peace Hospital (the 980th Hospital of the People's Liberation Army Joint Service Support Force), Shijiazhuang, China
| | - Li-Sha Bao
- Department of Pediatrics, NICU, Bethune International Peace Hospital (the 980th Hospital of the People's Liberation Army Joint Service Support Force), Shijiazhuang, China
| | - Ru-Jia Liang
- Department of Pediatrics, NICU, Bethune International Peace Hospital (the 980th Hospital of the People's Liberation Army Joint Service Support Force), Shijiazhuang, China
| | - Xiao-Ying Zhao
- Department of Pediatrics, NICU, Bethune International Peace Hospital (the 980th Hospital of the People's Liberation Army Joint Service Support Force), Shijiazhuang, China
| | - Zhi Li
- Department of Pediatrics, NICU, Bethune International Peace Hospital (the 980th Hospital of the People's Liberation Army Joint Service Support Force), Shijiazhuang, China
| | - Zhi-Fang Du
- Department of Pediatrics, NICU, Bethune International Peace Hospital (the 980th Hospital of the People's Liberation Army Joint Service Support Force), Shijiazhuang, China
| | - Shao-Guang Lv
- Department of Pediatrics, NICU, Bethune International Peace Hospital (the 980th Hospital of the People's Liberation Army Joint Service Support Force), Shijiazhuang, China
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33
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Park SH, Lee JH, Choi SJ, Kim HS, Kim NH. Fatal Encephalopathy Caused by a Urea Cycle Disorder. J Clin Neurol 2021; 17:325-327. [PMID: 33835757 PMCID: PMC8053538 DOI: 10.3988/jcn.2021.17.2.325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/22/2020] [Accepted: 12/22/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Soo Hyun Park
- Department of Neurology, Inha University Hospital, Incheon, Korea.,Department of Critical Care Medicine, Inha University Hospital, Incheon, Korea
| | - Jung Hwan Lee
- Department of Gastroenterology, Inha University Hospital, Incheon, Korea.,Department of Internal Medicine, Inha University Hospital, Incheon, Korea
| | - Seok Jin Choi
- Department of Neurology, Inha University Hospital, Incheon, Korea
| | - Hee Sup Kim
- Department of Pediatrics, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Nam Hee Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea.
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34
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Hidaka M, Higashi E, Uwatoko T, Uwatoko K, Urashima M, Takashima H, Watanabe Y, Kitazono T, Sugimori H. Late-onset ornithine transcarbamylase deficiency: a rare cause of recurrent abnormal behavior in adults. Acute Med Surg 2020; 7:e565. [PMID: 32995020 PMCID: PMC7507316 DOI: 10.1002/ams2.565] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 07/16/2020] [Accepted: 07/31/2020] [Indexed: 11/12/2022] Open
Abstract
Background Ornithine transcarbamylase is an enzyme of the urea cycle, which produces urea from ammonia. Although ornithine transcarbamylase deficiency mainly occurs as a severe neonatal-onset disease, a late-onset form that could become symptomatic from infancy to adulthood is also known. Case presentation A 34-year-old man presented with sudden onset of abnormal behavior, lethargy, and hyperammonemia (108 µmol/L). He had recently increased daily protein intake, which suggested urea cycle disorder. After initiation of protein-restricted diet and treatment with arginine and sodium phenylbutyrate, his symptoms resolved, along with a decrease in the ammonia level. An R40H(c.119G > A) mutation in the OTC gene was identified. Conclusion Awareness of adult onset ornithine transcarbamylase deficiency in a patient with acute psychiatric symptoms due to hyperammonemia is important.
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Affiliation(s)
- Masaoki Hidaka
- Department of Cerebrovascular Medicine Stroke Center Saga Prefecture Medical Centre Koseikan Saga Japan
| | - Eiji Higashi
- Department of Cerebrovascular Medicine Stroke Center Saga Prefecture Medical Centre Koseikan Saga Japan
| | - Takeshi Uwatoko
- Department of Cerebrovascular Medicine Stroke Center Saga Prefecture Medical Centre Koseikan Saga Japan
| | - Kiku Uwatoko
- Department of Neurology Stroke Center Saga Prefecture Medical Centre Koseikan Saga Japan
| | - Mayumi Urashima
- Department of Pediatrics Saga Prefecture Medical Centre Koseikan Saga Japan
| | - Hiroshi Takashima
- Department of Neurology Stroke Center Saga Prefecture Medical Centre Koseikan Saga Japan
| | - Yoriko Watanabe
- Research Institute of Medical Mass Spectrometry Kurume University School of Medicine Kurume Japan.,Department of Pediatrics and Child Health Kurume University School of Medicine Kurume Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Hiroshi Sugimori
- Department of Cerebrovascular Medicine Stroke Center Saga Prefecture Medical Centre Koseikan Saga Japan
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35
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Anderson D, Jain-Ghai S, Sligl WI. Adult-onset presentation of a urea cycle disorder necessitating intensive care unit admission. Can J Anaesth 2020; 67:1094-1096. [PMID: 32207085 DOI: 10.1007/s12630-020-01618-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/15/2020] [Accepted: 02/27/2020] [Indexed: 11/28/2022] Open
Affiliation(s)
- Dustin Anderson
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
| | - Shailly Jain-Ghai
- Department of Medical Genetics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Wendy I Sligl
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
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36
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Torkzaban M, Haddad A, Baxter JK, Berghella V, Gahl WA, Al-Kouatly HB. Maternal ornithine transcarbamylase deficiency, a genetic condition associated with high maternal and neonatal mortality every clinician should know: A systematic review. Am J Med Genet A 2019; 179:2091-2100. [PMID: 31441224 DOI: 10.1002/ajmg.a.61329] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/25/2019] [Accepted: 07/29/2019] [Indexed: 12/30/2022]
Abstract
Ornithine transcarbamylase deficiency (OTCD) is a rare X-linked urea cycle disorder. Maternal OTCD can lead to life-threatening hyperammonemia if untreated. We aimed to compare the outcomes of maternal OTCD when diagnosis is known prior to pregnancy to when diagnosis is made during pregnancy. We performed a systematic literature review on maternal OTCD using the databases Ovid MEDLINE and PubMed from 1982 through 2018. Studies were included if addressed maternal OTCD signs, symptoms, and detailed pregnancy outcomes. We calculated the median or the mean for continuous variables and percentages for categorical variables. Of 36 cases of maternal OTCD, 20 (55%) were diagnosed prior to pregnancy while 16 (45%) were not. In the 20 patients diagnosed prior to pregnancy, 7 (35%) had either a neurologic or psychiatric presentation during pregnancy or postpartum. Two hyperammonemic patients (11%) experienced ICU admission, dialysis, and coma with no maternal deaths. All had a favorable outcome. In the 16 patients not known to have maternal OTCD prior to pregnancy, 13 (81%) had neurologic or psychiatric presentation during pregnancy or postpartum. Four presented with hyperemesis gravidarum. Eleven (69%) hyperammonemic patients had ICU admission and coma and 7 (47%) of them had dialysis. There were 5 (31%) maternal deaths. Three patients (19%) had prolonged hospitalization course. Overall, three male neonatal deaths were reported. Three other male children had liver transplant. Maternal OTCD is associated with high maternal and neonatal morbidity and mortality when diagnosis is made during pregnancy compared to when diagnosis is known prior to pregnancy.
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Affiliation(s)
- Mehnoosh Torkzaban
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Andrew Haddad
- Department of Obstetrics & Gynecology, Medstar Washington Hospital Center, Washington, District of Columbia.,Medical Genetics Branch, National Human Genome Research Institute, National Institute of Health, Bethesda, Maryland
| | - Jason K Baxter
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - William A Gahl
- Section on Human Biochemical Genetics, Medical Genetics Branch, National Human Genome Research Institute, National Institute of Health, Bethesda, Maryland
| | - Huda B Al-Kouatly
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
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