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van den Bersselaar L, Gubbels M, Jungbluth H, Schouten M, van der Kooi A, Quinlivan R, Scheffer G, Riazi S, Snoeck M, Voermans N. Perioperative Care for Patients with Neuromuscular Disorders in the Netherlands –A Questionnaire Study Among Anaesthesiologists, Neurologists and Clinical Geneticists. J Neuromuscul Dis 2022; 9:765-775. [DOI: 10.3233/jnd-221512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Patients with neuromuscular disorders are at increased risk of suffering perioperative complications. Current knowledge concerning this topic is based on small retrospective studies and expert opinion. Therefore, an individualized multidisciplinary approach to perioperative anaesthesia planning is invaluable to anticipate difficulties and to optimize outcomes. Objective: To evaluate current practice regarding preoperative counselling and perioperative care of neuromuscular patients, with the aim to facilitate standardization and improvement of perioperative care for neuromuscular patients. Methods: A questionnaire-based cross-sectional, observational study was conducted between July, 1st 2020 and December, 31st, 2020 in Dutch anaesthesia, neurology and clinical genetics departments. Main outcome measures were 1.) frequency of consultation requests for neuromuscular patients prior to surgery, 2.) current practice, educational activities and departmental approach to this topic and 3.) preoperative counselling of neuromuscular patients. Results: A total of 83 departments participated. Consultations for a neuromuscular patient scheduled for anaesthesia were requested from anaesthesia and neurology department only infrequently. Local guidelines concerning perioperative care of neuromuscular patients were available in 36.4% of the participating departments. Quality of specific training for residents and staff anaesthetists/neurologists covering perioperative care of neuromuscular patients was rated as ‘very good’ or ‘good’ by 42.9% . Neuromuscular patients scheduled for surgery were ‘always’ or ‘often’ discussed in multidisciplinary meetings involving anaesthesiologists and neurologists in 20.8% of the participating departments. Conclusion: Perioperative care for neuromuscular patients in the Netherlands is highly variable and might benefit from guidelines, education of health care professionals and multidisciplinary meetings between anaesthesiologists and neurologists on a regular basis.
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Affiliation(s)
- L.R. van den Bersselaar
- Malignant Hyperthermia Investigation Unit, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - M.H.M. Gubbels
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - H. Jungbluth
- Department of Paediatric Neurology, Neuromuscular Service, Evelina’s Children Hospital, Guy’s and St Thomas’ Hospitals NHS Foundation Trust, London, United Kingdom
- Randall Centre for Cell and Molecular Biophysics, Muscle Signalling Section, Faculty of Life Sciences and Medicine (FoLSM), King’s College London, London, United Kingdom
| | - M.I. Schouten
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A.J. van der Kooi
- Department of Neurology, Amsterdam University Medical Center, Neuroscience institute, Amsterdam, The Netherlands
| | - R. Quinlivan
- MRC Centre for Neuromuscular Diseases, National Hospital, UCL Queen Square Institute of Neurology, London, United Kingdom
| | - G.J. Scheffer
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - S. Riazi
- Department of Anesthesiology and Pain Medicine, Malignant Hyperthermia Investigation Unit, University Health Network, University of Toronto, Toronto, Canada
| | - M.M.J. Snoeck
- Malignant Hyperthermia Investigation Unit, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - N.C. Voermans
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
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Yin S, Ma L, Shao T, Zhang M, Guan Y, Wang L, Hu Y, Chen X, Han H, Shen N, Qiu W, Geng H, Yu Y, Li S, Yu W, Liu M, Li D. Enhanced genome editing to ameliorate a genetic metabolic liver disease through co-delivery of adeno-associated virus receptor. SCIENCE CHINA-LIFE SCIENCES 2020; 65:718-730. [PMID: 32815069 DOI: 10.1007/s11427-020-1744-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 04/20/2020] [Indexed: 12/24/2022]
Abstract
Genome editing through adeno-associated viral (AAV) vectors is a promising gene therapy strategy for various diseases, especially genetic disorders. However, homologous recombination (HR) efficiency is extremely low in adult animal models. We assumed that increasing AAV transduction efficiency could increase genome editing activity, especially HR efficiency, for in vivo gene therapy. Firstly, a mouse phenylketonuria (PKU) model carrying a pathogenic R408W mutation in phenylalanine hydroxylase (Pah) was generated. Through co-delivery of the general AAV receptor (AAVR), we found that AAVR could dramatically increase AAV transduction efficiency in vitro and in vivo. Furthermore, co-delivery of SaCas9/sgRNA/donor templates with AAVR via AAV8 vectors increased indel rate over 2-fold and HR rate over 15-fold for the correction of the single mutation in PahR408W mice. Moreover, AAVR co-injection successfully increased the site-specific insertion rate of a 1.4 kb Pah cDNA by 11-fold, bringing the HR rate up to 7.3% without detectable global off-target effects. Insertion of Pah cDNA significantly decreased the Phe level and ameliorated PKU symptoms. This study demonstrates a novel strategy to dramatically increase AAV transduction which substantially enhanced in vivo genome editing efficiency in adult animal models, showing clinical potential for both conventional and genome editing-based gene therapy.
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Affiliation(s)
- Shuming Yin
- Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai, 200241, China
| | - Lie Ma
- Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai, 200241, China
| | - Tingting Shao
- Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai, 200241, China
| | - Mei Zhang
- Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai, 200241, China
| | - Yuting Guan
- Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai, 200241, China
| | - Liren Wang
- Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai, 200241, China
| | - Yaqiang Hu
- Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai, 200241, China
| | - Xi Chen
- Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai, 200241, China
| | - Honghui Han
- Bioray Laboratories Inc., Shanghai, 200241, China
| | - Nan Shen
- Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Wenjuan Qiu
- Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Hongquan Geng
- Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Yongguo Yu
- Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Shichang Li
- College of Physical Education and Health, East China Normal University, Shanghai, 200241, China.,Key Laboratory of Adolescent Health Assessment and Exercise Intervention, Ministry of Education, College of Physical Education and Health, East China Normal University, Shanghai, 200241, China
| | - Weishi Yu
- Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai, 200241, China.,CIPHER GENE LLC, Beijing, 100089, China
| | - Mingyao Liu
- Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai, 200241, China
| | - Dali Li
- Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai, 200241, China.
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3
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Caletti MT, Bettocchi I, Baronio F, Brodosi L, Cataldi S, Petroni ML, Cassio A, Marchesini G. Maternal PKU: Defining phenylalanine tolerance and its variation during pregnancy, according to genetic background. Nutr Metab Cardiovasc Dis 2020; 30:977-983. [PMID: 32409273 DOI: 10.1016/j.numecd.2020.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 02/11/2020] [Accepted: 02/12/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND AIMS Phenylketonuria (PKU)-affected women may become pregnant, and dietary phenylalanine (Phe) intake must be adjusted according to Phe tolerance. We report our experience with maternal PKU in relation to genotype PKU heterogeneity. METHODS AND RESULTS A total of 10 pregnancies in 7 PKU women (7 different genotypes) were followed up as part of personalized care. Phe tolerance during preconception and pregnancy was assessed by strict dietary control and weekly Phe measurement (blood spots) in relation to genotype. Most women had stopped PKU diet during childhood or adolescence and six pregnancies were unplanned; a phenylalanine-restricted diet was reinstituted soon after conception. Women were classified according to their Phe levels at birth screening and genotype. Phe tolerance increased systematically in the course of pregnancy in all cases, but the increase was different in subjects with classic PKU (cPKU) when compared with cases with mild hyperphenylalaninemia (mHPA), both on average (+297 mg/day in cPKU vs. 597 in mHPA; P = 0.017) and as percentage (+107% in cPKU vs. +17% in mHPA). Notably, Phe tolerance also varied in the same women in the course of different pregnancies, when body weight gain was also different. Two newborns from the same cPKU mother (unplanned pregnancies on free diet) were affected by congenital alterations. CONCLUSIONS Several factors influence metabolic phenotype in maternal PKU, to an unpredictable extent even in the same woman. The number of maternal PKU cases is growing in dedicated Nutrition Units, and the burden associated with careful management of this condition for the health care system should be adequately considered.
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Affiliation(s)
- Maria T Caletti
- Unit of Metabolic Diseases and Clinical Dietetics - DIMEC, "Alma Mater" University, Bologna, Italy
| | - Ilaria Bettocchi
- Unit of Pediatrics - DIMEC, "Alma Mater" University, Bologna, Italy
| | - Federico Baronio
- Unit of Pediatrics - DIMEC, "Alma Mater" University, Bologna, Italy
| | - Lucia Brodosi
- Unit of Metabolic Diseases and Clinical Dietetics - DIMEC, "Alma Mater" University, Bologna, Italy
| | - Sara Cataldi
- Unit of Metabolic Diseases and Clinical Dietetics - DIMEC, "Alma Mater" University, Bologna, Italy
| | - Maria L Petroni
- Unit of Metabolic Diseases and Clinical Dietetics - DIMEC, "Alma Mater" University, Bologna, Italy
| | | | - Giulio Marchesini
- Unit of Metabolic Diseases and Clinical Dietetics - DIMEC, "Alma Mater" University, Bologna, Italy.
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4
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Sousa C, Almeida MF, Sousa Barbosa C, Martins E, Janeiro P, Tavares de Almeida I, MacDonald A, Rocha JC. The European Phenylketonuria Guidelines and the challenges on management practices in Portugal. J Pediatr Endocrinol Metab 2019; 32:623-629. [PMID: 31141484 DOI: 10.1515/jpem-2018-0527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 04/01/2019] [Indexed: 12/30/2022]
Abstract
Background Phenylketonuria (PKU) management practices differ between and within countries. In 2007, the Portuguese Society for Metabolic Disorders (SPDM) approved the Portuguese Consensus (PC) for the nutritional treatment of PKU. The recently published European PKU Guidelines (EPG, 2017) systematically reviewed recent evidence and aimed to harmonise treatment protocols in Europe. The objective of this study was to appraise the EPG acceptance and implementation in Portuguese treatment centres. Methods An electronic questionnaire was prepared and the link was sent to 135 SPDM members. It outlined the 10 EPG key recommendations and compared each statement with the consensus recommendations published by SPDM. Responses were recorded and descriptive analyses were performed. Results Twenty-five professionals completed the questionnaire, and over half (56%) were nutritionists/dieticians. At least one questionnaire from each of the 10 national treatment centres was returned. In general, responders accepted most of the recommendations. However, only the recommendation about target phenylalanine (Phe) concentrations between 120 and 360 μmol/L for patients <12 years received 100% consensus with a further seven recommendations gaining over 70% consensus. Almost half of the professionals (48%, n = 12) required further discussion about the EPG-safe upper target blood Phe concentration (600 μmol/L) suggested for patients aged ≥12 years. Almost one third (32%, n = 8) failed to agree with the recommendation in the EPG-proposed classification of Phe hydroxylase (PAH) deficiency. Conclusions The EPG received overall good acceptance, but there was divided opinion about some recommendations which require further discussion before implementation by the Portuguese treatment centres.
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Affiliation(s)
- Cátia Sousa
- Centro de Genética Médica, Centro Hospitalar Universitário do Porto - CHUP, Porto, Portugal.,Faculdade de Ciências da Nutrição e Alimentação da Universidade do Porto, Porto, Portugal
| | - Manuela Ferreira Almeida
- Centro de Genética Médica, Centro Hospitalar Universitário do Porto - CHUP, Porto, Portugal.,Centro de Referência na área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto - CHUP, Porto, Portugal.,Unit for Multidisciplinary Research in Biomedicine, Abel Salazar Institute of Biomedical Sciences, University of Porto-UMIB/ICBAS/UP, Porto, Portugal
| | - Catarina Sousa Barbosa
- Centro de Genética Médica, Centro Hospitalar Universitário do Porto - CHUP, Porto, Portugal.,Faculdade de Ciências da Nutrição e Alimentação da Universidade do Porto, Porto, Portugal
| | - Esmeralda Martins
- Centro de Referência na área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto - CHUP, Porto, Portugal.,Unit for Multidisciplinary Research in Biomedicine, Abel Salazar Institute of Biomedical Sciences, University of Porto-UMIB/ICBAS/UP, Porto, Portugal
| | - Patrícia Janeiro
- Reference Centre for the Treatment of Inborn Errors of Metabolism, CHULN, Lisbon, Portugal
| | | | | | - Júlio César Rocha
- Centro de Genética Médica, Centro Hospitalar Universitário do Porto - CHUP, Porto, Portugal.,Centro de Referência na área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto - CHUP, Porto, Portugal.,Centro de Genética Médica, Doutor Jacinto de Magalhães, CHUP, EPE, Praça Pedro Nunes 88, 4099-028 Porto, Portugal.,Center for Health Technology and Services Research [CINTESIS], Porto, Portugal
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5
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van Wegberg AMJ, MacDonald A, Ahring K, Bélanger-Quintana A, Blau N, Bosch AM, Burlina A, Campistol J, Feillet F, Giżewska M, Huijbregts SC, Kearney S, Leuzzi V, Maillot F, Muntau AC, van Rijn M, Trefz F, Walter JH, van Spronsen FJ. The complete European guidelines on phenylketonuria: diagnosis and treatment. Orphanet J Rare Dis 2017; 12:162. [PMID: 29025426 PMCID: PMC5639803 DOI: 10.1186/s13023-017-0685-2] [Citation(s) in RCA: 421] [Impact Index Per Article: 60.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 07/11/2017] [Indexed: 12/22/2022] Open
Abstract
Phenylketonuria (PKU) is an autosomal recessive inborn error of phenylalanine metabolism caused by deficiency in the enzyme phenylalanine hydroxylase that converts phenylalanine into tyrosine. If left untreated, PKU results in increased phenylalanine concentrations in blood and brain, which cause severe intellectual disability, epilepsy and behavioural problems. PKU management differs widely across Europe and therefore these guidelines have been developed aiming to optimize and standardize PKU care. Professionals from 10 different European countries developed the guidelines according to the AGREE (Appraisal of Guidelines for Research and Evaluation) method. Literature search, critical appraisal and evidence grading were conducted according to the SIGN (Scottish Intercollegiate Guidelines Network) method. The Delphi-method was used when there was no or little evidence available. External consultants reviewed the guidelines. Using these methods 70 statements were formulated based on the highest quality evidence available. The level of evidence of most recommendations is C or D. Although study designs and patient numbers are sub-optimal, many statements are convincing, important and relevant. In addition, knowledge gaps are identified which require further research in order to direct better care for the future.
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Affiliation(s)
- A. M. J. van Wegberg
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, PO BOX 30.001, 9700 RB Groningen, The Netherlands
| | - A. MacDonald
- Dietetic Department, Birmingham Children’s Hospital, Birmingham, UK
| | - K. Ahring
- Department of PKU, Kennedy Centre, Glostrup, Denmark
| | - A. Bélanger-Quintana
- Metabolic Diseases Unit, Department of Paediatrics, Hospital Ramon y Cajal Madrid, Madrid, Spain
| | - N. Blau
- University Children’s Hospital, Dietmar-Hoppe Metabolic Centre, Heidelberg, Germany
- University Children’s Hospital Zürich, Zürich, Switzerland
| | - A. M. Bosch
- Department of Paediatrics, Division of Metabolic Disorders, Academic Medical Centre, University Hospital of Amsterdam, Amsterdam, The Netherlands
| | - A. Burlina
- Division of Inherited Metabolic Diseases, Department of Paediatrics, University Hospital of Padova, Padova, Italy
| | - J. Campistol
- Neuropaediatrics Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - F. Feillet
- Department of Paediatrics, Hôpital d’Enfants Brabois, CHU Nancy, Vandoeuvre les Nancy, France
| | - M. Giżewska
- Department of Paediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology of the Developmental Age, Pomeranian Medical University, Szczecin, Poland
| | - S. C. Huijbregts
- Department of Clinical Child and Adolescent Studies-Neurodevelopmental Disorders, Faculty of Social Sciences, Leiden University, Leiden, The Netherlands
| | - S. Kearney
- Clinical Psychology Department, Birmingham Children’s Hospital, Birmingham, UK
| | - V. Leuzzi
- Department of Paediatrics, Child Neurology and Psychiatry, Sapienza University of Rome, Via dei Sabelli 108, 00185 Rome, Italy
| | - F. Maillot
- CHRU de Tours, Université François Rabelais, INSERM U1069, Tours, France
| | - A. C. Muntau
- University Children’s Hospital, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - M. van Rijn
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, PO BOX 30.001, 9700 RB Groningen, The Netherlands
| | - F. Trefz
- Department of Paediatrics, University of Heidelberg, Heidelberg, Germany
| | - J. H. Walter
- Medicine, Manchester Academic Health Sciences Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - F. J. van Spronsen
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, PO BOX 30.001, 9700 RB Groningen, The Netherlands
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6
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Jurecki ER, Cederbaum S, Kopesky J, Perry K, Rohr F, Sanchez-Valle A, Viau KS, Sheinin MY, Cohen-Pfeffer JL. Adherence to clinic recommendations among patients with phenylketonuria in the United States. Mol Genet Metab 2017; 120:190-197. [PMID: 28162992 DOI: 10.1016/j.ymgme.2017.01.001] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 01/04/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Assess current management practices of phenylketonuria (PKU) clinics across the United States (US) based on the key treatment metrics of blood phenylalanine (Phe) concentrations and blood Phe testing frequency, as well as patient adherence to their clinic's management practice recommendations. METHODS An online survey was conducted with medical professionals from PKU clinics across the US from July to September 2015. Forty-four clinics participated in the survey and account for approximately half of PKU patients currently followed in clinics in the US (Berry et al., 2013). RESULTS The majority of PKU clinics recommended target blood Phe concentrations to be between 120 and 360μM for all patients; the upper threshold was relaxed by some clinics for adult patients (from 360 to 600μM) and tightened for patients who are pregnant/planning to become pregnant (to 240μM). Patient adherence to these recommendations (percentage of patients with blood Phe below the upper recommended threshold) was age-dependent, decreasing from 88% in the 0-4years age group to 33% in adults 30+ years. Patient adherence to recommendations for blood testing frequency followed a similar trend. Higher staffing intensity (specialists per 100 PKU patients) was associated with better patient adherence to clinics' blood Phe concentrations recommendations. CONCLUSION Clinic recommendations of target blood Phe concentrations in the US are now stricter compared to prior years, and largely reflect recent guidelines by the American College of Medical Genetics and Genomics (Vockley et al., 2014). Adherence to recommended Phe concentrations remains suboptimal, especially in older patients. However, despite remaining above the guidelines, actual blood Phe concentrations in adolescents and adults are lower than those reported in the past (Walter et al., 2002; Freehauf et al., 2013). Continued education and support for PKU patients by healthcare professionals, including adequate clinic staffing, are needed to improve adherence. Future research is needed to understand how to improve adherence to reduce the number of patients lost to follow-up, as the findings of this and similar surveys do not address how to keep patients in clinic.
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Affiliation(s)
- E R Jurecki
- Medical Affairs, BioMarin Pharmaceutical, Inc., Novato, CA, United States.
| | - S Cederbaum
- Department of Psychiatry, University of California, Los Angeles, CA, United States; Department of Pediatrics, and Human Genetics, University of California, Los Angeles, CA, United States
| | - J Kopesky
- Department of Clinical Nutrition, Children's Hospital of Wisconsin, Milwaukee, WI, United States; Department of Genetics, Children's Hospital of Wisconsin, Milwaukee, WI, United States
| | - K Perry
- Trinity Partners, Waltham, MA, United States
| | - F Rohr
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, United States
| | - A Sanchez-Valle
- Division of Genetics and Metabolism, University of South Florida, Florida, United States
| | - K S Viau
- Department of Pediatrics, Division of Medical Genetics, University of Utah, Salt Lake City, UT, United States
| | - M Y Sheinin
- Trinity Partners, Waltham, MA, United States
| | - J L Cohen-Pfeffer
- Medical Affairs, BioMarin Pharmaceutical, Inc., Novato, CA, United States
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Pena MJ, de Almeida MF, van Dam E, Ahring K, Bélanger-Quintana A, Dokoupil K, Gokmen-Ozel H, Lammardo AM, MacDonald A, Robert M, Rocha JC. Protein substitutes for phenylketonuria in Europe: access and nutritional composition. Eur J Clin Nutr 2016; 70:785-9. [PMID: 27117930 DOI: 10.1038/ejcn.2016.54] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 02/01/2016] [Accepted: 02/26/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Protein substitutes (PS) are an essential component in the dietary management of phenylketonuria (PKU). PS are available as phenylalanine-free amino-acid mixtures (AAM), glycomacropeptide-based PS (GMP) and large neutral amino acids (LNAA). There is a lack of information regarding their availability in different countries and comparison of their nutritional composition is limited. The objectives of this study were to identify the number of PS available in different European countries and Turkey and to compare their nutritional composition. SUBJECTS/METHODS Members of the European Nutritionist Expert Panel on PKU (ENEP) (Portugal, Spain, Belgium, Italy, Germany, Netherlands, United Kingdom, Denmark and Turkey) provided data on PS available in each country. The nutritional composition of PS available in Portugal was analyzed. RESULTS The number of PS available in each country varied from 30 (Turkey) to 105 (Germany), with a median of 64. GMP was available only in Portugal, whereas LNAA was an option in Portugal, Italy, Turkey and Denmark. Some PS were designed for weaning. Many PS did not contain added fat and fiber. GMP contained the highest carbohydrate (CHO) and energy content as well as higher LNAA content compared with AAM. Only one AAM contained added fructo-oligosaccharides and galacto-oligosaccharides. AAM designed for the first year of life had the highest CHO, fat and LNAA contribution. Liquid AAM had lower CHO and fat contents compared with powdered AAM, but contained higher LNAA. CONCLUSIONS There was widely dissimilar numbers of PS available in different countries. Nutritional composition of different PS was variable and should be considered before prescription.
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Affiliation(s)
- M J Pena
- Centro de Genética Médica, Centro Hospitalar do Porto (CHP), Porto, Portugal
| | - M F de Almeida
- Centro de Genética Médica, Centro Hospitalar do Porto (CHP), Porto, Portugal.,Unit for Multidisciplinary Research in Biomedicine (UMIB), Instituto de Ciências Biomédicas Abel Salazar (ICBAS), University of Porto, Porto, Portugal
| | - E van Dam
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, The Netherlands
| | - K Ahring
- Department of PKU, Kennedy Centre, Copenhagen University Hospital, Glostrup, Denmark
| | - A Bélanger-Quintana
- Unidad Enfermedades Metabolicas Servicio de Pediatria Hospital Ramon y Cajal, Madrid, Spain
| | - K Dokoupil
- Department of Metabolism and Nutrition, Dr von Hauner Children's Hospital, University of Munich, Munich, Germany
| | - H Gokmen-Ozel
- Department of Nutrition and Dietetics, Hacettepe University, Ankara, Turkey
| | - A M Lammardo
- Department of Pediatrics, San Paolo Hospital University of Milan, Milan, Italy
| | | | - M Robert
- Nutrition and Metabolism Unit, Hôpital Universitaire des Enfants Reine Fabiola, Brussels, Belgium
| | - J C Rocha
- Centro de Genética Médica, Centro Hospitalar do Porto (CHP), Porto, Portugal.,Faculdade de Ciências da Saúde, Universidade Fernando Pessoa, Porto, Portugal.,Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
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8
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Diagnostic and management practices for phenylketonuria in 19 countries of the South and Eastern European Region: survey results. Eur J Pediatr 2016; 175:261-72. [PMID: 26350228 PMCID: PMC4724370 DOI: 10.1007/s00431-015-2622-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 08/10/2015] [Accepted: 08/14/2015] [Indexed: 01/17/2023]
Abstract
UNLABELLED To avoid potentially severe outcomes, phenylketonuria (PKU) must be detected as soon as possible after birth and managed with life-long treatment. A questionnaire-based survey was performed to document diagnosis and management practices for PKU in a region of Southern and Eastern Europe. Prevalence and management data were obtained from 37/59 (63 %) centres within 19/22 (86%) contacted countries (N = 8600 patients). The main results' analysis was based on completed questionnaires obtained from 31 centres (53%) within 15 countries (68%). A median of 10 % of patients per centre had been diagnosed after the newborn period. Metabolic dieticians and specialised adult PKU clinics were lacking in 36 and 84% of centres, respectively. In 26% of centres, treatment initiation was delayed until >15 days of life. Blood phenylalanine (Phe) thresholds to start treatment and upper Phe targets were inconsistent across centres. Ten percent of centres reported monitoring Phe every 2 weeks for pregnant women with PKU, which is insufficient to minimise risk of neonatal sequalae. Sapropterin dihydrochloride treatment was available in 48% of centres, with 24-h responsiveness tests most common (36%). Only one centre among the five countries lacking newborn screening provided a completed questionnaire. CONCLUSION Targeted efforts by health care professionals and governments are needed to optimise diagnostic and management approaches for PKU in Southern and Eastern Europe. WHAT IS KNOWN PKU must be detected early and optimally managed throughout life to avoid poor outcomes, yet newborn screening is not universal and diagnostic and management practices for PKU are known to vary widely between different centres and countries. Targeted efforts by health care professionals and governments are needed to optimise diagnostic and management approaches. WHAT IS NEW PKU management practices are documented in 19 South and Eastern European countries indicating a heterogeneous situation across the region. Key areas for improvement identified in surveyed centres include a need for comprehensive screening in all countries, increased number of metabolic dietitians and specialised adult PKU clinics, delayed time to treatment initiation, appropriate Phe thresholds, Phe targets and monitoring frequencies, and universal access to currently available treatment options.
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9
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Pena MJ, Almeida MF, van Dam E, Ahring K, Bélanger-Quintana A, Dokoupil K, Gokmen-Ozel H, Lammardo AM, MacDonald A, Robert M, Rocha JC. Special low protein foods for phenylketonuria: availability in Europe and an examination of their nutritional profile. Orphanet J Rare Dis 2015; 10:162. [PMID: 26693706 PMCID: PMC4688958 DOI: 10.1186/s13023-015-0378-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 12/14/2015] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Special low protein foods (SLPF) are essential in the nutritional management of patients with phenylketonuria (PKU). The study objectives were to: 1) identify the number of SLPF available for use in eight European countries and Turkey and 2) analyse the nutritional composition of SLPF available in one of these countries. METHODS European Nutritionist Expert Panel on PKU (ENEP) members (Portugal, Spain, Belgium, Italy, Germany, Netherlands, UK, Denmark and Turkey) provided data on SPLF available in each country. The nutritional composition of Portuguese SLPF was compared with regular food products. RESULTS The number of different SLPF available in each country varied widely with a median of 107 [ranging from 73 (Portugal) and 256 (Italy)]. Food analysis of SLPF available from a single country (Portugal) indicated that the mean phenylalanine content was higher in low protein baby cereals (mean 48 mg/100 g) and chocolate/energy bars/jelly (mean 41 mg/100 g). The energy content of different foods from a sub-group of SLPF (cookies) varied widely between 23 and 96 kcal/cookie. Low protein bread had a high fat content [mean 5.8 g/100 g (range 3.7 to 10)] compared with 1.6 g/100 g in regular bread. Seven of the 12 SLPF sub-groups (58 %) did not declare any vitamin content, and only 4 (33 %) identified a limited number of minerals. CONCLUSIONS Whilst equal and free access to all SLPF is desirable, the widely variable nutritional composition requires careful nutritional knowledge of all products when prescribed for individual patients with PKU. There is a need for more specific nutritional standards for special low protein foods.
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Affiliation(s)
- Maria João Pena
- Centro de Genética Médica Doutor Jacinto de Magalhães, CHP EPE, Praça Pedro Nunes, 88, 4099-028, Porto, Portugal.
| | - Manuela Ferreira Almeida
- Centro de Genética Médica Doutor Jacinto de Magalhães, CHP EPE, Praça Pedro Nunes, 88, 4099-028, Porto, Portugal. .,Unit for Multidisciplinary Research in Biomedicine, Abel Salazar Institute of Biomedical Sciences, University of Porto-UMIB/ICBAS/UP, Porto, Portugal.
| | - Esther van Dam
- Beatrix Children's Hospital, University of Groningen, University Medical Center' Groningen Netherlands, Groningen, Netherlands.
| | | | - Amaya Bélanger-Quintana
- Unidad Enfermedades Metabolicas Servicio de Pediatria Hospital Ramon y Cajal, Madrid, Spain.
| | - Katharina Dokoupil
- Department of Metabolism and Nutrition, Dr. von Hauner Children's Hospital, University of Munich, Munich, Germany.
| | - Hulya Gokmen-Ozel
- Department of Nutrition and Dietetics, Hacettepe University, Ankara, Turkey.
| | - Anna Maria Lammardo
- Department of Pediatrics, San Paolo Hospital University of Milan, Milan, Italy.
| | | | - Martine Robert
- Nutrition and Metabolism Unit, Hôpital Universitaire des Enfants Reine Fabiola, Brussels, Belgium.
| | - Júlio César Rocha
- Centro de Genética Médica Doutor Jacinto de Magalhães, CHP EPE, Praça Pedro Nunes, 88, 4099-028, Porto, Portugal. .,Faculdade de Ciências da Saúde, Universidade Fernando Pessoa, Porto, Portugal. .,Center for Health Technology and Services Research (CINTESIS), Porto, Portugal.
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10
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Zerjav Tansek M, Groselj U, Angelkova N, Anton D, Baric I, Djordjevic M, Grimci L, Ivanova M, Kadam A, Kotori V, Maksic H, Marginean O, Margineanu O, Miljanovic O, Moldovanu F, Muresan M, Nanu M, Samardzic M, Sarnavka V, Savov A, Stojiljkovic M, Suzic B, Tincheva R, Tahirovic H, Toromanovic A, Usurelu N, Battelino T. Phenylketonuria screening and management in southeastern Europe - survey results from 11 countries. Orphanet J Rare Dis 2015; 10:68. [PMID: 26025111 PMCID: PMC4451731 DOI: 10.1186/s13023-015-0283-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 05/12/2015] [Indexed: 08/30/2023] Open
Abstract
BACKGROUND We aimed to assess the current state of PKU screening and management in the region of southeastern Europe. METHODS A survey was performed involving all identified professionals responsible for the PKU management in the 11 countries from South-Eastern region of Europe (Albania, Bulgaria, Bosnia and Herzegovina, Croatia, Kosovo, Macedonia, Moldova, Montenegro, Romania, Serbia, Slovenia). The questionnaire was designed to assess the characteristics regarding PKU management in three main areas: nation-wide characteristics, PKU screening, and characteristics of the PKU management in the responding centre. It consisted of 56 questions. The distribution and collection of the questionnaires (via e-mail) was taking place from December 2013 to March 2014. RESULTS Responses from participants from 11 countries were included; the countries cumulative population is approx. 52.5 mio. PKU screening was not yet introduced in 4 of 11 countries. Reported PKU incidences ranged from 1/7325 to 1/39338 (and were not known for 5 countries). National PKU guidelines existed in 5 of 11 countries and 7 of 11 countries had PKU registry (registries included 40 to 194 patients). The number of PKU centers in each country varied from 1 to 6. Routine genetic diagnostics was reported in 4 of 11 countries. Most commonly used laboratory method to assess phenylalanine levels was fluorometric. Tetrahydrobiopterine was used in only 2 of 11 countries. Most frequently, pediatricians were caring for the patients. Dietitian was a member of PKU team in only 4 of 11 countries, while regular psychological assessments were performed in 6 of 11 countries. Patient's PKU society existed in 7 of 11 countries. CONCLUSIONS The region of southeastern Europe was facing certain important challenges of PKU screening and management. Neonatal PKU screening should be introduced throughout the region. Furthermore, PKU management was falling behind internationally established standards-of-care in many aspects.
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Affiliation(s)
- Mojca Zerjav Tansek
- University Children's Hospital Ljubljana, UMC Ljubljana, Ljubljana, Slovenia.
| | - Urh Groselj
- University Children's Hospital Ljubljana, UMC Ljubljana, Ljubljana, Slovenia.
| | | | - Dana Anton
- Clinical Hospital for Children "Sfanta Maria", Iasi, Romania.
| | - Ivo Baric
- Department of Pediatrics, University Hospital Center Zagreb, Zagreb, Croatia. .,School of Medicine, University of Zagreb, Zagreb, Croatia.
| | - Maja Djordjevic
- Mother and Child Health Care Institute of Serbia, Belgrade, Serbia.
| | - Lindita Grimci
- University Hospital Center "Mother Teresa", Tirana, Albania.
| | | | - Adil Kadam
- University Pediatric Hospital Sofia, Sofia, Bulgaria.
| | - Vjosa Kotori
- Pediatric Clinic, University Clinical Center Pristina, Pristina, Kosovo.
| | - Hajrija Maksic
- University Clinical Center Sarajevo, Sarajevo, Bosnia and Herzegovina.
| | | | | | - Olivera Miljanovic
- Institute for Sick Children, Clinical Center of Montenegro, Podgorica, Montenegro.
| | | | - Mariana Muresan
- Clinical Hospital for Children "Iuliu Hateganu", Cluj-Napoca, Romania.
| | - Michaela Nanu
- Mother and Child Health Care Institute "Alfred Rusescu", Bucharest, Romania.
| | - Mira Samardzic
- Institute for Sick Children, Clinical Center of Montenegro, Podgorica, Montenegro.
| | - Vladimir Sarnavka
- Department of Pediatrics, University Hospital Center Zagreb, Zagreb, Croatia.
| | | | - Maja Stojiljkovic
- Institute of Molecular Genetics and Genetic Engineering, University of Belgrade, Belgrade, Serbia.
| | - Biljana Suzic
- Children Hospital Banja Luka, Banja Luka, Republic of Srpska, Bosnia and Herzegovina.
| | | | - Husref Tahirovic
- Department of Medical Sciences, Academy of Sciences and Arts of Bosnia and Herzegovina, Sarajevo, Bosnia and Herzegovina.
| | - Alma Toromanovic
- Department of Pediatrics, University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina.
| | - Natalia Usurelu
- Institute of Mother and Child, Centre of Reproductive Health and Medical Genetics, Chisinau, Moldova.
| | - Tadej Battelino
- University Children's Hospital Ljubljana, UMC Ljubljana, Ljubljana, Slovenia. .,Department of Pediatrics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
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11
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New insights in growth of phenylketonuric patients. Eur J Pediatr 2015; 174:651-9. [PMID: 25367055 DOI: 10.1007/s00431-014-2446-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 10/14/2014] [Accepted: 10/20/2014] [Indexed: 10/24/2022]
Abstract
UNLABELLED Treatment of phenylketonuria involves a restriction in the intake of natural proteins. This can lead to growth impairment. Weight, height and body mass index of 109 hyperphenylalaninemic patients (mild hyperphenylalaninemia (HPA) and phenylketonuria (PKU)) were determined from birth until 18 years, every 6 months, and differences to the healthy population, depending on the age, sex and phenotype, were analyzed. Data collection was longitudinal retrospective during 31 years. Statistical analysis of z-score values was performed by advanced statistical tools. Long-term evolution of anthropometric z-scores showed no significant statistical differences between PKU and mild HPA individuals, according to the general population. For PKU individuals, height is slightly lower and weight slightly higher than in the healthy population, but differences are smaller than one standard deviation. Nevertheless, over-time evolutions of female height z-scores are different in each type of pathology, with a crossover between 8 and 12 years (p = 0.0186). CONCLUSIONS It is nowadays possible to achieve a long-term normal growth in PKU patients with appropriate dietary treatment. There is however an acceleration of growth up to 8 years old for PKU female patients that leads to a slightly lower final height. Detection of this behaviour was possible by using nonlinear mixed effects models.
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12
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Comparison of tandem mass spectrometry and amino acid analyzer for phenylalanine and tyrosine monitoring—Implications for clinical management of patients with hyperphenylalaninemia. Clin Biochem 2015; 48:14-8. [DOI: 10.1016/j.clinbiochem.2014.09.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 09/11/2014] [Accepted: 09/14/2014] [Indexed: 11/23/2022]
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13
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Camp KM, Parisi MA, Acosta PB, Berry GT, Bilder DA, Blau N, Bodamer OA, Brosco JP, Brown CS, Burlina AB, Burton BK, Chang CS, Coates PM, Cunningham AC, Dobrowolski SF, Ferguson JH, Franklin TD, Frazier DM, Grange DK, Greene CL, Groft SC, Harding CO, Howell RR, Huntington KL, Hyatt-Knorr HD, Jevaji IP, Levy HL, Lichter-Konecki U, Lindegren ML, Lloyd-Puryear MA, Matalon K, MacDonald A, McPheeters ML, Mitchell JJ, Mofidi S, Moseley KD, Mueller CM, Mulberg AE, Nerurkar LS, Ogata BN, Pariser AR, Prasad S, Pridjian G, Rasmussen SA, Reddy UM, Rohr FJ, Singh RH, Sirrs SM, Stremer SE, Tagle DA, Thompson SM, Urv TK, Utz JR, van Spronsen F, Vockley J, Waisbren SE, Weglicki LS, White DA, Whitley CB, Wilfond BS, Yannicelli S, Young JM. Phenylketonuria Scientific Review Conference: state of the science and future research needs. Mol Genet Metab 2014; 112:87-122. [PMID: 24667081 DOI: 10.1016/j.ymgme.2014.02.013] [Citation(s) in RCA: 157] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 02/25/2014] [Accepted: 02/26/2014] [Indexed: 01/17/2023]
Abstract
New developments in the treatment and management of phenylketonuria (PKU) as well as advances in molecular testing have emerged since the National Institutes of Health 2000 PKU Consensus Statement was released. An NIH State-of-the-Science Conference was convened in 2012 to address new findings, particularly the use of the medication sapropterin to treat some individuals with PKU, and to develop a research agenda. Prior to the 2012 conference, five working groups of experts and public members met over a 1-year period. The working groups addressed the following: long-term outcomes and management across the lifespan; PKU and pregnancy; diet control and management; pharmacologic interventions; and molecular testing, new technologies, and epidemiologic considerations. In a parallel and independent activity, an Evidence-based Practice Center supported by the Agency for Healthcare Research and Quality conducted a systematic review of adjuvant treatments for PKU; its conclusions were presented at the conference. The conference included the findings of the working groups, panel discussions from industry and international perspectives, and presentations on topics such as emerging treatments for PKU, transitioning to adult care, and the U.S. Food and Drug Administration regulatory perspective. Over 85 experts participated in the conference through information gathering and/or as presenters during the conference, and they reached several important conclusions. The most serious neurological impairments in PKU are preventable with current dietary treatment approaches. However, a variety of more subtle physical, cognitive, and behavioral consequences of even well-controlled PKU are now recognized. The best outcomes in maternal PKU occur when blood phenylalanine (Phe) concentrations are maintained between 120 and 360 μmol/L before and during pregnancy. The dietary management treatment goal for individuals with PKU is a blood Phe concentration between 120 and 360 μmol/L. The use of genotype information in the newborn period may yield valuable insights about the severity of the condition for infants diagnosed before maximal Phe levels are achieved. While emerging and established genotype-phenotype correlations may transform our understanding of PKU, establishing correlations with intellectual outcomes is more challenging. Regarding the use of sapropterin in PKU, there are significant gaps in predicting response to treatment; at least half of those with PKU will have either minimal or no response. A coordinated approach to PKU treatment improves long-term outcomes for those with PKU and facilitates the conduct of research to improve diagnosis and treatment. New drugs that are safe, efficacious, and impact a larger proportion of individuals with PKU are needed. However, it is imperative that treatment guidelines and the decision processes for determining access to treatments be tied to a solid evidence base with rigorous standards for robust and consistent data collection. The process that preceded the PKU State-of-the-Science Conference, the conference itself, and the identification of a research agenda have facilitated the development of clinical practice guidelines by professional organizations and serve as a model for other inborn errors of metabolism.
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Affiliation(s)
- Kathryn M Camp
- Office of Dietary Supplements, National Institutes of Health, Bethesda, MD 20982, USA.
| | - Melissa A Parisi
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.
| | | | - Gerard T Berry
- Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Deborah A Bilder
- Department of Psychiatry, University of Utah, Salt Lake City, UT 84108, USA.
| | - Nenad Blau
- University Children's Hospital, Heidelberg, Germany; University Children's Hospital, Zürich, Switzerland.
| | - Olaf A Bodamer
- University of Miami Miller School of Medicine, Miami, FL 33136, USA.
| | - Jeffrey P Brosco
- University of Miami Mailman Center for Child Development, Miami, FL 33101, USA.
| | | | | | - Barbara K Burton
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA.
| | - Christine S Chang
- Agency for Healthcare Research and Quality, Rockville, MD 20850, USA.
| | - Paul M Coates
- Office of Dietary Supplements, National Institutes of Health, Bethesda, MD 20982, USA.
| | - Amy C Cunningham
- Tulane University Medical School, Hayward Genetics Center, New Orleans, LA 70112, USA.
| | | | - John H Ferguson
- Office of Rare Diseases Research, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20982, USA.
| | | | | | - Dorothy K Grange
- Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO 63110, USA.
| | - Carol L Greene
- University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Stephen C Groft
- Office of Rare Diseases Research, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20982, USA.
| | - Cary O Harding
- Oregon Health & Science University, Portland, OR 97239, USA.
| | - R Rodney Howell
- University of Miami Miller School of Medicine, Miami, FL 33136, USA.
| | | | - Henrietta D Hyatt-Knorr
- Office of Rare Diseases Research, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20982, USA.
| | - Indira P Jevaji
- Office of Research on Women's Health, National Institutes of Health, Bethesda, MD 20817, USA.
| | - Harvey L Levy
- Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Uta Lichter-Konecki
- George Washington University, Children's National Medical Center, Washington, DC 20010, USA.
| | | | | | | | | | - Melissa L McPheeters
- Vanderbilt Evidence-based Practice Center, Institute for Medicine and Public Health, Nashville, TN 37203, USA.
| | - John J Mitchell
- McGill University Health Center, Montreal, Quebec H3H 1P3, Canada.
| | - Shideh Mofidi
- Maria Fareri Children's Hospital of Westchester Medical Center, Valhalla, NY 10595, USA.
| | - Kathryn D Moseley
- University of Southern California Keck School of Medicine, Los Angeles, CA 90033, USA.
| | - Christine M Mueller
- Office of Orphan Products Development, U.S. Food and Drug Administration, Silver Spring, MD 20993, USA.
| | - Andrew E Mulberg
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20993, USA.
| | - Lata S Nerurkar
- Office of Rare Diseases Research, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20982, USA.
| | - Beth N Ogata
- University of Washington, Seattle, WA 98195, USA.
| | - Anne R Pariser
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20993, USA.
| | - Suyash Prasad
- BioMarin Pharmaceutical Inc., San Rafael, CA 94901, USA.
| | - Gabriella Pridjian
- Tulane University Medical School, Hayward Genetics Center, New Orleans, LA 70112, USA.
| | | | - Uma M Reddy
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.
| | | | | | - Sandra M Sirrs
- Vancouver General Hospital, University of British Columbia, Vancouver V5Z 1M9, Canada.
| | | | - Danilo A Tagle
- National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Susan M Thompson
- The Children's Hospital at Westmead, Sydney, NSW 2145, Australia.
| | - Tiina K Urv
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Jeanine R Utz
- University of Minnesota, Minneapolis, MN 55455, USA.
| | - Francjan van Spronsen
- University of Groningen, University Medical Center of Groningen, Beatrix Children's Hospital, Netherlands.
| | - Jerry Vockley
- University of Pittsburgh, Pittsburgh, PA 15224, USA.
| | - Susan E Waisbren
- Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Linda S Weglicki
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Desirée A White
- Department of Psychology, Washington University, St. Louis, MO 63130, USA.
| | | | - Benjamin S Wilfond
- Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA 98101, USA.
| | | | - Justin M Young
- The Young Face, Facial Plastic and Reconstructive Surgery, Cumming, GA 30041, USA.
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14
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Hagedorn TS, van Berkel P, Hammerschmidt G, Lhotáková M, Saludes RP. Requirements for a minimum standard of care for phenylketonuria: the patients' perspective. Orphanet J Rare Dis 2013; 8:191. [PMID: 24341788 PMCID: PMC3878574 DOI: 10.1186/1750-1172-8-191] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Accepted: 11/12/2013] [Indexed: 11/22/2022] Open
Abstract
Phenylketonuria (PKU, ORPHA716) is an inherited disorder that affects about one in every 10,000 children born in Europe. Early and continuous application of a modified diet is largely successful in preventing the devastating brain damage associated with untreated PKU. The management of PKU is inconsistent: there are few national guidelines, and these tend to be incomplete and implemented sporadically. In this article, the first-ever pan- European patient/carer perspective on optimal PKU care, the European Society for Phenylketonuria and Allied Disorders (E.S.PKU) proposes recommendations for a minimum standard of care for PKU, to underpin the development of new pan-European guideline for the management of PKU. New standards of best practice should guarantee equal access to screening, treatment and monitoring throughout Europe. Screening protocols and interpretation of screening results should be standardised. Experienced Centres of Expertise are required, in line with current European Union policy, to guarantee a defined standard of multidisciplinary treatment and care for all medical and social aspects of PKU. Women of childbearing age require especially intensive management, due to the risk of severe risks to the foetus conferred by uncontrolled PKU. All aspects of treatment should be reimbursed to ensure uniform access across Europe to guideline-driven, evidence-based care. The E.S.PKU urges PKU healthcare professionals caring for people with PKU to take the lead in developing evidence based guidelines on PKU, while continuing to play an active role in serving as the voice of patients and their families, whose lives are affected by the condition.
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Affiliation(s)
- Tobias S Hagedorn
- European Society for Phenylketonuria and Allied Disorders (E,S,PKU), Melsele, Belgium.
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15
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Mei L, Song P, Kokudo N, Xu L, Tang W. Current situation and prospects of newborn screening and treatment for Phenylketonuria in China - compared with the current situation in the United States, UK and Japan. Intractable Rare Dis Res 2013; 2:106-14. [PMID: 25343113 PMCID: PMC4204557 DOI: 10.5582/irdr.2013.v2.4.106] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 11/30/2013] [Indexed: 12/16/2022] Open
Abstract
Phenylketonuria (PKU) is a treat-able and prevent-able inborn error of metabolism which leads to severe mental retardation and neurobehavioral abnormalities. A screening program, especially for early detection, combined with a Phe-restricted therapeutic diet can help to control the process of PKU of most patients. The China government has put more emphasis on newborn screening and treatment against PKU, yet by comparing the situation of newborn screening and treatment against PKU in China and the relatively developed countries - United States, United Kingdom and Japan, the newborn screening and treatment against PKU in China is relatively weak and many deficiencies are found. More studies concerning multi-stage target blood Phe concentration criteria, a policy that requires newborn screening has to be taken, better financial support for newborn screening, publicity for newborn screening, and national guidelines for treatment of PKU may be prospects in China and may provide some support for better development of newborn screening and treatment against PKU in China.
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Affiliation(s)
- Lin Mei
- Department of Health Care Management and Maternal and Child Health, Shandong University, Ji'nan, Shandong, China
- Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Peipei Song
- Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Norihiro Kokudo
- Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Lingzhong Xu
- Department of Health Care Management and Maternal and Child Health, Shandong University, Ji'nan, Shandong, China
- Address correspondence to: Dr. Lingzhong Xu, Department of Health Care Management and Maternal and Child Health, NO.110 mailbox, Shandong University, 44 Wenhuaxi Road, Ji'nan 250012, China. E-mail:
| | - Wei Tang
- Department of Health Care Management and Maternal and Child Health, Shandong University, Ji'nan, Shandong, China
- Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Dr. Wei Tang, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. E-mail:
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16
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Abstract
BACKGROUND PKU patients on a strict low protein diet get most of their folic acid intake from protein substitute. Several protein substitutes contain high amounts of this vitamin. Concern has been raised about the safety of high levels of folic acid, especially in relation to cancer risk. METHODS This cross-sectional study included 34 children and 22 adults with PKU. A dietary interview was performed and intake of folic acid and vitamin B12 from protein substitute was calculated for patients compliant with their protein substitute. Intakes of folic acid and vitamin B12 were compared with plasma levels of folate, vitamin B12, and homocysteine. RESULTS Children aged 2-9 years had the highest intake of folic acid according to RDI (449 %), and children aged 7-10 years had the highest intake of folic acid according to UL (155 %). Median plasma folate level in PKU children was two times the upper reference level and in PKU adults well above. Children between 10 and 13 years had the highest level of plasma folate. Young children had both a high intake and high plasma levels of vitamin B12. Homocysteine levels were low or in the lower part of the normal reference range in most patients. CONCLUSION Children with PKU are at a particular risk of receiving folic acid high above RDI and many children with PKU receive doses above the UL. Many PKU patients have a very high level of plasma folate related to a very high content of folic acid in many of their protein substitutes.
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17
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Abstract
INTRODUCTION Phenylketonuria (PKU) is caused by mutation of the enzyme, phenylalanine (Phe) hydroxylase (PAH). The hyperphenylalaninemia characteristic of PKU causes devastating neurological damage if not identified and treated at birth with a Phe-restricted diet. Sapropterin dihydrochloride, a pharmaceutical formulation of the natural cofactor for PAH (6R-tetrahydrobiopterin; BH4), is now available for the management of hyperphenylalaninemia in some PKU patients, including BH4 deficiencies. Sapropterin dihydrochloride improves dietary Phe tolerance in about 20% of patients with PKU. AREAS COVERED This evaluation describes the identification of patients suitable for treatment of sapropterin dihydrochloride, together with its indications, therapeutic properties and efficacy. Furthermore, the article reviews its safety and tolerability in patients with PKU or BH4 deficiency. EXPERT OPINION A reduction in blood Phe of at least 30% occurred in ∼ 20 - 30% of sapropterin-treated PKU patients (mostly with milder forms of PKU). Treatment with sapropterin resulted in clinically significant and sustained reductions in blood Phe concentrations and increased dietary Phe tolerance in well-designed clinical studies in PKU patients who responded to BH4. Successful treatment with sapropterin may lead to a relaxation of the Phe-restricted diet, although continued monitoring of blood Phe is required. Sapropterin was well tolerated.
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Affiliation(s)
- Nenad Blau
- University Children's Hospital, Division of Inborn Metabolic Diseases, Department of General Pediatrics, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany.
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18
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Freehauf C, Van Hove JLK, Gao D, Bernstein L, Thomas JA. Impact of geographic access to care on compliance and metabolic control in phenylketonuria. Mol Genet Metab 2013. [PMID: 23177662 DOI: 10.1016/j.ymgme.2012.09.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To study the impact of geographic access to care on metabolic control and compliance in phenylketonuria (PKU). STUDY DESIGN Phenylalanine (Phe) levels and number of samples obtained were abstracted from a data base of 76 patients age <21 years and compared for age, sex, and distance to clinic. Levels and number of samples were compared to the clinic guidelines for age. RESULTS There was a strong positive correlation between age and Phe levels in adolescents and young adults while age and number of samples submitted were negatively correlated. There was not a significant correlation between Phe levels and distance to clinic, nor was there a significant difference in the Phe levels by distant categories (Denver metro, Front Range, distant area). However, there was a decrease in number of samples sent compared to clinic guidelines by distance, with patients residing in distant areas (>100 miles) sending significantly less samples. CONCLUSION Geographic access to care does not impact control of Phe levels, but it does affect the number of monitoring samples sent to the clinic. Age groups of adolescents and young adults have a strong impact on both control of Phe levels and number of monitoring samples compared to clinic guidelines.
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Affiliation(s)
- Cynthia Freehauf
- Department of Pediatrics, University of Colorado, Education 2 South, Mailstop 8400, 13121 East 17th Avenue, Aurora, CO 80045, USA.
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Campistol J, González MJ, Gutiérrez AP, Vilaseca MA. [Treatment and control of patients with phenylketonuria: results from the Collaborative Group of Spanish Follow-up Units]. Med Clin (Barc) 2012; 138:185-91. [PMID: 21794880 DOI: 10.1016/j.medcli.2011.03.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Revised: 03/03/2011] [Accepted: 03/03/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND OBJECTIVE To evaluate the management of phenylketonuria (PKU) in Spanish metabolic units and to develop a patients registry. PATIENTS AND METHODS PKU patients diagnosed and/or followed up in Spain, with phenylalanine values before treatment > 360 μmol/L. Registered anonymous data are those yielded by the units during 2010. RESULTS Data from the 18 Spanish Follow-up Units were collected. Eighty-three per cent of Units are multidisciplinary, all of them corresponding to control patients of all ages, with uniform management criteria. Data of 688 PKU patients were registered (median: 14 years [1 month-53 years], 41.5% are presently > 18-year-old. 71.8% patients came from neonatal screening; 15.8% have mild-PKU, 26% moderate-PKU and 51.5% classic-PKU. 78.6% patients are treated with protein-restricted diet, 9.3% with BH4 and free diet and 7.8% with BH4 and diet. Dietary control was good in 58.6% patients, intermediate in 26% and poor in 15.3%. Median (range) intellectual quotients was 97 (25-145). The number of neurological complications in late diagnosed patients was three-times higher than those of neonatal screening patients. 13.3% of adults had university studies and 37.5% had a stable couple. CONCLUSIONS This study allows for the first time the evaluation of the PKU management by Spanish PKU Follow-up Units, as well as the analysis and registry of controlled PKU patients. The study makes evident the need of adult Follow-up Units and the importance of neonatal screening for PKU patients prognosis.
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Affiliation(s)
- Jaume Campistol
- Servicio de Neurología, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues, Barcelona, Spain.
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Belanger-Quintana A, Dokoupil K, Gokmen-Ozel H, Lammardo AM, MacDonald A, Motzfeldt K, Nowacka M, Robert M, van Rijn M, Ahring K. Diet in phenylketonuria: a snapshot of special dietary costs and reimbursement systems in 10 international centers. Mol Genet Metab 2012; 105:390-4. [PMID: 22217429 DOI: 10.1016/j.ymgme.2011.12.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 12/06/2011] [Accepted: 12/06/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND AND AIMS To gather exploratory data on the costs and reimbursement of special dietary foods used in the management of phenylketonuria (PKU) from ten international specialist PKU centers. METHODS Experts from each center provided data on retail costs of the three most frequently used phenylalanine-free protein substitutes and low-protein foods at their center; reimbursement of protein substitutes and low-protein foods; and state monetary benefits provided to PKU patients. RESULTS The mean annual cost of protein substitutes across 4 age groups (2 y, 8 y, 15 y and adults) ranged from €4273 to €21,590 per patient. The cost of low-protein products also differed; the mean cost of low-protein bread varied from €0.04 to €1.60 per 100 kcal. All protein substitutes were either fully reimbursed or covered by health insurance. However, reimbursement for low-protein products varied and state benefits differed between centers. CONCLUSIONS The variation in the cost and reimbursement of diet therapy and the level of additional state benefits for PKU patients demonstrates the large difference in expenditure on and access to PKU dietary products. This highlights the inequality between healthcare systems and access to special dietary products for people with PKU, ultimately leading to patients in some countries receiving better care than others.
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Affiliation(s)
- A Belanger-Quintana
- Unidad de Enfermedades Metabolicas, Servicio de Pediatría, Hospital Ramón y Cajal, Madrid, Spain
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21
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Belanger-Quintana A, Martínez-Pardo M. Physical development in patients with phenylketonuria on dietary treatment: a retrospective study. Mol Genet Metab 2011; 104:480-4. [PMID: 21878401 DOI: 10.1016/j.ymgme.2011.08.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Revised: 08/05/2011] [Accepted: 08/05/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVES To evaluate the growth and physical development in patients with phenylalanine hydroxylase deficiency who follow exclusively dietary treatment. METHODS Anthropometric measurements of 160 patients with hyperphenylalaninemia who were followed at our center over a 25 year period were obtained. Only patients treated exclusively with a protein-restrictive diet supplemented with amino acid mixtures were included. Height, weight and body mass index were measured at birth, at diagnosis, at 6 and 12 months of age, and annually until 18 years of age in patients with phenylketonuria or until 9 years of age in patients with mild hyperphenylalaninemia and compared to official national reference values. The final height of PKU patients was also compared to their expected family height. RESULTS The analysis of z scores suggested no significant differences in physical development between PKU patients and the healthy population during the study period. The final height of PKU patients revealed that they were 2 to 4 cm taller than expected when compared to the mean family height (p<0.001). The mean weight and BMI at puberty suggested that many patients with severe PKU, but not other phenotypes, were overweight during this period. CONCLUSION Physical development can be optimal in PKU patients regardless of their phenotype and the severity of the diet. A tendency to excessive weight gain is seen in adolescence in the most severe phenotypes.
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Affiliation(s)
- Amaya Belanger-Quintana
- Unidad de Enfermedades Metabólicas, Servicio de Pediatría, Hospital Ramón y Cajal, Madrid, Spain.
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22
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Abstract
Currently, there is no international consensus on how patients with phenylketonuria (PKU) (or milder forms of hyperphenylalaninaemia) should be followed in clinical practice. Guidelines concerning the frequency and type of assessments that should be made according to age usually focus on blood phenylalanine concentrations. A need exists for improved guidelines on how to do the follow-up of individuals with PKU/milder forms of hyperphenylalaninaemia. An interdisciplinary approach for monitoring patients is required, involving relevant clinical investigations and regular contact with a clinician and dietician/nutritionist as well as contact with social health worker, psychologist and neurologist, at least at request. This chapter presents a scheme for follow-up. However, by no means this scheme aims to present the one for all time follow-up programme. The scheme for follow-up may rather serve as a start for further discussion in larger groups of professionals in collaboration with patients and their parents. A number of questions remain unanswered, and further research is still needed to fine-tune the management of PKU at different ages.
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van Spronsen FJ. Mild hyperphenylalaninemia: to treat or not to treat. J Inherit Metab Dis 2011; 34:651-6. [PMID: 21347590 PMCID: PMC3183992 DOI: 10.1007/s10545-011-9283-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Revised: 12/20/2010] [Accepted: 01/14/2011] [Indexed: 11/21/2022]
Abstract
One of the issues to be resolved in phenylketonuria is whether patients with mild hyperphenylalaninemia need treatment, or in other words, in what patients treatment needs to be started. Do patients need treatment when phenylalanine concentrations in blood are >360 μmol/L or >600 μmol/L? This paper reviews the literature on the outcome of untreated patients with mild hyperphenylalaninemia to try to determine whether outcome is normal. The paper concludes that there is, in fact, only one paper that can be used to answer this question. Therefore, the question is whether we may rely on one paper to draw conclusions or whether more research is necessary to determine whether all patients with phenylalanine concentrations >360 μmol/L or all patients with phenylalanine concentrations >600 μmol/L require treatment.
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ten Hoedt AE, de Sonneville LMJ, Francois B, ter Horst NM, Janssen MCH, Rubio-Gozalbo ME, Wijburg FA, Hollak CEM, Bosch AM. High phenylalanine levels directly affect mood and sustained attention in adults with phenylketonuria: a randomised, double-blind, placebo-controlled, crossover trial. J Inherit Metab Dis 2011; 34:165-71. [PMID: 21153445 PMCID: PMC3026661 DOI: 10.1007/s10545-010-9253-9] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Revised: 11/09/2010] [Accepted: 11/17/2010] [Indexed: 11/21/2022]
Abstract
The main debate in the treatment of Phenylketonuria (PKU) is whether adult patients need the strict phenylalanine (Phe)-restricted diet. Physicians and patients lack evidence-based guidelines to help them make well-informed choices. We have carried out the first randomised double-blind placebo-controlled trial into the effects of short-term elevation of Phe levels on neuropsychological functions and mood of adults with PKU. Nine continuously treated adults with PKU underwent two 4-week supplementation periods: one with Phe, mimicking normal dietary intake, and one with placebo in randomly allocated order via a randomisation coding list in a double-blind cross-over design. A set of neuropsychological tests (Amsterdam Neuropsychological Tasks) was administered at the end of each study period. In addition, patients and for each patient a friend or relative, completed weekly Profile of Mood States (POMS) questionnaires, evaluating the patients' mood. Phe levels were measured twice weekly. Mean plasma Phe levels were significantly higher during Phe supplementation compared with placebo (p = 0.008). Neuropsychological tests demonstrated an impairment in sustained attention during Phe supplementation (p = 0.029). Both patients and their friend or relative reported lower scores on the POMS questionnaires during Phe supplementation (p = 0.017 and p = 0.040, respectively). High plasma Phe levels have a direct negative effect on both sustained attention and on mood in adult patients with PKU. A Phe-restricted "diet for life" might be an advisable option for many.
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Affiliation(s)
- Amber E. ten Hoedt
- Department of Pediatrics (H7-270), Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | | | - Baudouin Francois
- Department of Metabolic Diseases, Centrum Pinocchio, Diepenbeek, Belgium
| | - Nienke M. ter Horst
- Department of Pediatrics (H7-270), Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Mirian C. H. Janssen
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - M. Estela Rubio-Gozalbo
- Department of Pediatrics and Laboratory Genetic Metabolic Diseases, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Frits A. Wijburg
- Department of Pediatrics (H7-270), Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Carla E. M. Hollak
- Department of Internal Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Annet M. Bosch
- Department of Pediatrics (H7-270), Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Demirkol M, Giżewska M, Giovannini M, Walter J. Follow up of phenylketonuria patients. Mol Genet Metab 2011; 104 Suppl:S31-9. [PMID: 22018725 DOI: 10.1016/j.ymgme.2011.08.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Revised: 07/31/2011] [Accepted: 08/07/2011] [Indexed: 11/26/2022]
Abstract
In recent years our understanding of the follow up policies for PKU has increased substantially. In particular, we now understand the importance of maintaining control of blood phenylalanine (phe) concentrations life-long to achieve the best long-term neuropsychological outcomes. The concordance with the follow up strategy remains a key challenge for the future, especially with respect to adolescents and young adults. The recent therapies could ease the burden of the dietary phe restriction for PKU patients and their families. The time may be right for revisiting the guidelines for follow up of PKU in order to address a number of important issues related to PKU management: promotion of breastfeeding to complementary feeding up to 2 years of age for prevention of early growth retardation and later overweight development, treatment advancements for metabolic control, blood phe and tyr variability, routine screening measures for nutritional biomarkers, neurocognitive and psychological assessments, bone pathology, understanding the challenges of compliance and transitioning into adulthood as an individual with PKU and addressing unmet needs in this population.
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Affiliation(s)
- M Demirkol
- Div Nutrition and Metabolism, Children's Hospital, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey.
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26
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Sharman R, Sullivan KA, Young RM, McGill JJ. Tyrosine monitoring in children with early and continuously treated phenylketonuria: results of an international practice survey. J Inherit Metab Dis 2010; 33 Suppl 3:S417-20. [PMID: 20882350 DOI: 10.1007/s10545-010-9211-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2010] [Revised: 08/19/2010] [Accepted: 09/07/2010] [Indexed: 11/29/2022]
Abstract
Investigations into the biochemical markers associated with executive function (EF) impairment in children with early and continuously treated phenylketonuria (ECT-PKU) remain largely phenylalanine-only focused, despite experimental data showing that a high phenylalanine:tyrosine (phe:tyr) ratio is more strongly associated with EF deficit than phe alone. A high phe:tyr ratio is hypothesized to lead to a reduction in dopamine synthesis within the brain, which in turn results in the development of EF impairment. This paper provides a snapshot of current practice in the monitoring and/or treatment of tyrosine levels in children with PKU, across 12 countries from Australasia, North America and Europe. Tyrosine monitoring in this population has increased over the last 5 years, with over 80% of clinics surveyed reporting routine monitoring of tyrosine levels in infancy alongside phe levels. Twenty-five percent of clinics surveyed reported actively treating/managing tyrosine levels (with supplemental tyrosine above that contained in PKU formulas) to ensure tyrosine levels remain within normal ranges. Anecdotally, supplemental tyrosine has been reported to ameliorate symptoms of both attention deficit hyperactivity disorder and depression in this population. EF assessment of children with ECT-PKU was likewise highly variable, with 50% of clinics surveyed reporting routine assessments of intellectual function. However when function was assessed, test instruments chosen tended towards global measures of IQ prior to school entry, rather than specific assessment of EF development. Further investigation of the role of tyrosine and its relationship with phe and EF development is needed to establish whether routine tyrosine monitoring and increased supplementation is recommended.
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Affiliation(s)
- Rachael Sharman
- School of Psychology and Counselling, Queensland University of Technology, PO Box 2434, QLD 4001, Queensland, Australia.
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27
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Abstract
Phenylketonuria is the most prevalent disorder caused by an inborn error in aminoacid metabolism. It results from mutations in the phenylalanine hydroxylase gene. Phenotypes can vary from a very mild increase in blood phenylalanine concentrations to a severe classic phenotype with pronounced hyperphenylalaninaemia, which, if untreated, results in profound and irreversible mental disability. Neonatal screening programmes identify individuals with phenylketonuria. The initiation of a phenylalanine-restricted diet very soon after birth prevents most of the neuropsychological complications. However, the diet is difficult to maintain and compliance is often poor, especially in adolescents, young adults, and pregnant women. Tetrahydrobiopterin stimulates phenylalanine hydroxylase activity in about 20% of patients, and in those patients serves as a useful adjunct to the phenylalanine-restricted diet because it increases phenylalanine tolerance and allows some dietary freedom. Possible future treatments include enzyme substitution with phenylalanine ammonia lyase, which degrades phenylalanine, and gene therapy to restore phenylalanine hydroxylase activity.
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Affiliation(s)
- Nenad Blau
- Division of Clinical Chemistry and Biochemistry, University Children's Hospital, Zurich, Switzerland.
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28
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Enns GM, Koch R, Brumm V, Blakely E, Suter R, Jurecki E. Suboptimal outcomes in patients with PKU treated early with diet alone: revisiting the evidence. Mol Genet Metab 2010; 101:99-109. [PMID: 20678948 DOI: 10.1016/j.ymgme.2010.05.017] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Revised: 05/27/2010] [Accepted: 05/28/2010] [Indexed: 11/22/2022]
Abstract
BACKGROUND The National Institute of Health (NIH) published a Consensus Statement on the screening and management of Phenylketonuria (PKU) in 2000. The panel involved in the development of this consensus statement acknowledged the lack of data regarding the potential for more subtle suboptimal outcomes and the need for further research into treatment options. In subsequent years, the approval of new treatment options for PKU and outcome data for patients treated from the newborn period by dietary therapy alone have become available. We hypothesized that a review of the PKU literature since 2000 would provide further evidence related to neurocognitive, psychosocial, and physical outcomes that could serve as a basis for reassessment of the 2000 NIH Consensus Statement. METHODS A systematic review of literature residing in PubMed, Scopus and PsychInfo was performed in order to assess the outcome data over the last decade in diet-alone early-treated PKU patients to assess the need for new recommendations and validity of older recommendations in light of new evidence. RESULTS The majority of publications (140/150) that contained primary outcome data presented at least one suboptimal outcome compared to control groups or standardized norms/reference values in at least one of the following areas: neurocognitive/psychosocial (N=60; 58 reporting suboptimal outcomes); quality of life (N=6; 4 reporting suboptimal outcomes); brain pathology (N=32; 30 reporting suboptimal outcomes); growth/nutrition (N=34; 29 reporting suboptimal outcomes); bone pathology (N=9; 9 reporting suboptimal outcomes); and/or maternal PKU (N=19; 19 reporting suboptimal outcomes). CONCLUSIONS Despite the remarkable success of public health programs that have instituted newborn screening and early introduction of dietary therapy for PKU, there is a growing body of evidence that suggests that neurocognitive, psychosocial, quality of life, growth, nutrition, bone pathology and maternal PKU outcomes are suboptimal. The time may be right for revisiting the 2000 NIH Consensus Statement in order to address a number of important issues related to PKU management, including treatment advancements for metabolic control in PKU, blood Phe variability, neurocognitive and psychological assessments, routine screening measures for nutritional biomarkers, and bone pathology.
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Affiliation(s)
- G M Enns
- Division of Medical Genetics, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Stanford, CA 94305-5208,USA.
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Feillet F, van Spronsen FJ, MacDonald A, Trefz FK, Demirkol M, Giovannini M, Bélanger-Quintana A, Blau N. Challenges and pitfalls in the management of phenylketonuria. Pediatrics 2010; 126:333-41. [PMID: 20624808 DOI: 10.1542/peds.2009-3584] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Despite recent advances in the management of phenylketonuria and hyperphenylalaninemia, important questions on the management of this disorder remain unanswered. Consensus exists on the need for neonatal screening and early treatment, yet disagreement persists over threshold levels of blood phenylalanine for starting treatment, target blood phenylalanine levels, and the management of older patient groups. The mainstay of treatment is a phenylalanine-restricted diet, but its application varies between and within countries. Beyond diet treatment, there is a lack of consensus on the use of newer treatments such as tetrahydrobiopterin. Although neonatal screening and early treatment has meant that most well-treated children grow up with near-normal IQ scores, the effect of relaxing metabolic control on cognitive and executive function later in life is still not fully understood. Although it is clear from the available literature that the active control of blood phenylalanine levels is of vital importance, there are other treatment-related factors that affect outcome. A uniform and firmly evidence-based approach to the management of phenylketonuria is required.
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Affiliation(s)
- François Feillet
- Service de Médecine Infantile 1, Centre de Référence des Maladies Héréditaires du Métabolisme, INSERM U 954, CHU Brabois Enfants, Vandoeuvre les Nancy, France
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30
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MacLeod EL, Clayton MK, van Calcar SC, Ney DM. Breakfast with glycomacropeptide compared with amino acids suppresses plasma ghrelin levels in individuals with phenylketonuria. Mol Genet Metab 2010; 100:303-8. [PMID: 20466571 PMCID: PMC2906609 DOI: 10.1016/j.ymgme.2010.04.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Accepted: 04/08/2010] [Indexed: 12/14/2022]
Abstract
Phenylketonuria (PKU) requires a lifelong low-phenylalanine (phe) diet where protein needs are met by consumption of a phe-free amino acid (AA) formula; complaints of persistent hunger are common. Foods made with glycomacropeptide (GMP), an intact protein that contains minimal phe and may promote satiety, provide an alternative to AA formula. The objective was to assess the ability of a GMP breakfast to promote satiety and affect plasma concentrations of AAs, insulin, and the appetite stimulating hormone ghrelin in those with PKU, when compared to an AA-based breakfast. Eleven PKU subjects (8 adults and 3 boys ages 11-14) served as their own controls in an inpatient metabolic study with two 4-day treatments: an AA-based diet followed by a diet replacing all AA formula with GMP foods. Plasma concentrations of AAs, insulin and ghrelin were obtained before and/or 180 min after breakfast. Satiety was assessed using a visual analog scale before, immediately after and 150 min after breakfast. Postprandial ghrelin concentration was significantly lower (p=0.03) with GMP compared to an AA-based breakfast, with no difference in fasting ghrelin. Lower postprandial ghrelin concentrations were associated with greater feelings of fullness after breakfast suggesting greater satiety with GMP compared to AAs. Postprandial concentrations of insulin and total plasma AAs were higher after a GMP breakfast compared to an AA-based breakfast consistent with slower absorption and less degradation of AAs from GMP. These results show sustained ghrelin suppression, and suggest greater satiety with ingestion of a meal containing GMP compared with AAs.
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Affiliation(s)
- Erin L. MacLeod
- Department of Nutritional Sciences, 1415 Linden Dr, University of Wisconsin, Madison, Wisconsin, 53706 USA
| | - Murray K. Clayton
- Departments of Statistics and Plant Pathology, 1210 W. Dayton St, University of Wisconsin, Madison, Wisconsin, 53706 USA
| | - Sandra C. van Calcar
- Waisman Center, 1500 Highland Ave, University of Wisconsin, Madison, Wisconsin, 53706 USA
| | - Denise M. Ney
- Department of Nutritional Sciences, 1415 Linden Dr, University of Wisconsin, Madison, Wisconsin, 53706 USA
- Waisman Center, 1500 Highland Ave, University of Wisconsin, Madison, Wisconsin, 53706 USA
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31
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van Spronsen FJ. Phenylketonuria management from an European perspective: a commentary. Mol Genet Metab 2010; 100:107-10. [PMID: 20363168 DOI: 10.1016/j.ymgme.2010.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Revised: 03/02/2010] [Accepted: 03/02/2010] [Indexed: 11/16/2022]
Abstract
Phenylketonuria is discussed from an European perspective, addressing the need of common definitions of terms commonly used, the need of a world-wide guideline on the diagnosis and treatment of phenylketonuria, the differences between existing European guidelines, and day-to-day care, further directives for the near future, and changing the concept from compliance to concordance, in which patients have a more clearly defined responsibility.
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Affiliation(s)
- Francjan J van Spronsen
- Beatrix Children's Hospital, University Medical Center of Groningen, University of Groningen, Groningen, The Netherlands.
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32
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MacLeod EL, Ney DM. Nutritional Management of Phenylketonuria. ANNALES NESTLE [ENGLISH ED.] 2010; 68:58-69. [PMID: 22475869 PMCID: PMC2901905 DOI: 10.1159/000312813] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Phenylketonuria (PKU) is caused by deficient activity of the enzyme phenylalanine hydroxylase, needed to convert the essential amino acid (AA) phenylalanine (phe) to tyrosine. In order to prevent neurological damage, lifelong adherence to a low-phe diet that is restricted in natural foods and requires ingestion of a phe-free AA formula to meet protein needs is required. The goal of nutritional management for those with PKU is to maintain plasma phe concentrations that support optimal growth, development, and mental functioning while providing a nutritionally complete diet. This paper reviews developing a lifelong dietary prescription for those with PKU, outcomes of nutritional management, compliance with the low-phe diet across the life cycle, and new options for nutritional management. An individualized dietary prescription is needed to meet nutrient requirements, and the adequacy of phe intake is monitored with assessment of blood phe levels. Elevated phe concentrations may occur due to illness, excessive or inadequate phe intake, or inadequate intake of AA formula. Although normal growth and development occurs with adherence to the low-phe diet, it is important to monitor vitamin, mineral and essential fatty acid status, especially in those who do not consume sufficient AA formula. Given the growing population of adults with PKU, further research is needed to understand the risks for developing osteoporosis and cardiovascular disease. There are promising new options to liberalize the diet and improve metabolic control such as tetrahydrobiopterin therapy or supplementation with large neutral AAs. Moreover, foods made with glycomacropeptide, an intact protein that contains minimal phe, improves the PKU diet by offering a palatable alternative to AA formula. In summary, continued efforts are needed to overcome the biggest challenge to living with PKU - lifelong adherence to the low-phe diet.
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Affiliation(s)
| | - Denise M. Ney
- Department of Nutritional Sciences, University of Wisconsin, Madison, Wisc., USA
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Blau N, Bélanger-Quintana A, Demirkol M, Feillet F, Giovannini M, MacDonald A, Trefz FK, van Spronsen F. Management of phenylketonuria in Europe: survey results from 19 countries. Mol Genet Metab 2010; 99:109-15. [PMID: 19800826 DOI: 10.1016/j.ymgme.2009.09.005] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2009] [Revised: 09/10/2009] [Accepted: 09/10/2009] [Indexed: 10/20/2022]
Abstract
To gain better insight in the most current diagnosis and treatment practices for phenylketonuria (PKU) from a broad group of experts, a European PKU survey was performed. The questionnaire, consisting of 33 questions, was sent to 243 PKU professionals in 165 PKU centers in 23 European countries. The responses were compiled and descriptive analyses were performed. One hundred and one questionnaires were returned by 93/165 centers (56%) from 19/23 European countries (83%). The majority of respondents (77%) managed patients of all age groups and more than 90% of PKU teams included physicians or dieticians/nutritionists. The greatest variability existed especially in the definition of PKU phenotypes, therapeutic blood phenylalanine (Phe) target concentrations, and follow-up practices for PKU patients. The tetrahydrobiopterin (BH4; sapropterin) loading test was performed by 54% of respondents, of which 61% applied a single dose test (20mg/kg over 24h). BH4 was reported as a treatment option by 34%. This survey documents differences in diagnostic and treatment practices for PKU patients in European centers. In particular, recommendations for the treatment decision varied greatly between different European countries. There is an urgent need to pool long-term data in PKU registries in order to generate an evidence-based international guideline.
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Affiliation(s)
- Nenad Blau
- University Children's Hospital, Zürich, Switzerland.
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MacLeod EL, Gleason ST, van Calcar SC, Ney DM. Reassessment of phenylalanine tolerance in adults with phenylketonuria is needed as body mass changes. Mol Genet Metab 2009; 98:331-7. [PMID: 19747868 PMCID: PMC2783926 DOI: 10.1016/j.ymgme.2009.07.016] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Revised: 07/31/2009] [Accepted: 07/31/2009] [Indexed: 11/22/2022]
Abstract
Lifelong treatment of phenylketonuria (PKU) includes a phenylalanine (phe) restricted diet that provides sufficient phe for growth and maintenance plus phe-free amino acid formula to meet requirements for protein, energy and micronutrients. Phe tolerance (mg phe/kg body weight/day) is the amount of phe those with PKU can consume and maintain acceptable blood phe levels; it requires individual assessment because of varying phenylalanine hydroxylase activity. The objective was to reassess phe tolerance in eight adults with PKU considering phe requirements, blood phe levels, genotype and phe tolerance at 5 years of age. Subjects had not received a personalized assessment of phe tolerance in several years, and five subjects were overweight, body mass index (BMI) 25-28. With the guidance of a metabolic dietitian, seven subjects increased phe tolerance (by 15-173%) without significantly increasing blood phe concentration. Increased phe tolerance was associated with both improved dietary compliance and inadequate phe intake at the onset of the protocol compared with current requirements. Improved dietary compliance reflected increased consumption of protein equivalents from amino acid formula and increased frequency of formula intake, from 2.2 to 3 times per day. Predictors of higher final phe tolerance following reassessment included being male and having a lower BMI (R(2)=0.588). This suggests that the rising trend of overweight and obesity may affect assessment of phe tolerance in adults. Therefore, interaction with the metabolic dietitian to reassess phe tolerance in relation to body mass is essential throughout adulthood to insure adequate intake of phe to support protein synthesis and prevent catabolism.
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Affiliation(s)
- Erin L. MacLeod
- Department of Nutritional Sciences, 1415 Linden Dr; University of Wisconsin, Madison, Wisconsin, 53706 USA
| | - Sally T. Gleason
- Department of Nutritional Sciences, 1415 Linden Dr; University of Wisconsin, Madison, Wisconsin, 53706 USA
| | - Sandra C. van Calcar
- Waisman Center, 1500 Highland Ave; University of Wisconsin, Madison, Wisconsin, 53706 USA
| | - Denise M. Ney
- Department of Nutritional Sciences, 1415 Linden Dr; University of Wisconsin, Madison, Wisconsin, 53706 USA
- Waisman Center, 1500 Highland Ave; University of Wisconsin, Madison, Wisconsin, 53706 USA
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Pollitt RJ. Newborn blood spot screening: new opportunities, old problems. J Inherit Metab Dis 2009; 32:395-9. [PMID: 19412659 DOI: 10.1007/s10545-009-9962-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2009] [Revised: 03/06/2009] [Accepted: 03/18/2009] [Indexed: 10/20/2022]
Abstract
Newborn screening is evolving very rapidly. Geographical coverage is expanding, particularly for common disorders such as congenital hypothyroidism. New technologies, particularly tandem mass spectrometry and high throughput mutation analysis, have increased greatly the range of disorders which could be covered. However, these new possibilities are being exploiting at very different rates in different countries. This is due in part to the different ways in which generally-accepted screening criteria, based on the ten principles of Wilson and Jungner, are being interpreted and applied to policy. The appropriate management of some of the conditions newly-detectable by screening also remains controversial and there is a pressing need to align screening policy and clinical practice. Critical analysis and careful collection of data on an international basis are required to resolve these issues.
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Affiliation(s)
- R J Pollitt
- Newborn Screening Laboratory, The Children's Hospital, Sheffield S10 2TH, UK.
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