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Mütze U, Scharré S, Schnabel-Besson E, Kuseyri Hübschmann O, Höster F, Tuncel AT, Kölker S, Opladen T. Newborn screening for neuro-metabolic disorders: Strategies, clinical benefits, and prerequisites for program expansion. Eur J Paediatr Neurol 2025; 56:84-96. [PMID: 40339400 DOI: 10.1016/j.ejpn.2025.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2024] [Revised: 03/30/2025] [Accepted: 03/31/2025] [Indexed: 05/10/2025]
Abstract
Newborn screening (NBS) is a successful program of secondary prevention for rare diseases, such as neuro-metabolic diseases, enabling early identification of affected individuals and pre-symptomatic treatment. Driven by innovations in high-throughput sequencing technologies, NBS panels have continued to grow and will probably be extended further in the future. However, implementing NBS for a disease is subject to various preconditions to maximize the benefit for the affected children, while avoiding harm to the screened healthy cohort, their families and the society. Ideally, data on clinical long-term benefit of NBS and early treatment is collected prior to NBS implementation through long-term observational studies and registries. In addition, NBS should be implemented as an iteratively evaluated public health program and the data collection should be accompanied by intra-operable long-term observational studies, ideally extended in international cooperations. In this review, the current expertise in NBS, the screening strategies and possible long-term clinical benefits are presented and discussed for several neuro-metabolic diseases, including propionic acidemia and isolated methylmalonic acidemias, homocystinurias, remethylation defects, acquired cobalamin (vitamin B12) deficiency, urea cycle disorders, tetrahydrobiopterin (BH4) and primary neurotransmitter disorders, as well as lysosomal storage disorders. Given these prerequisites, several of the neuro-metabolic diseases discussed here might be part of future NBS programs worldwide.
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Affiliation(s)
- Ulrike Mütze
- Heidelberg University, Medical Faculty of Heidelberg, Department of Pediatrics I, Division of Pediatric Neurology and Metabolic Medicine, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany.
| | - Svenja Scharré
- Heidelberg University, Medical Faculty of Heidelberg, Department of Pediatrics I, Division of Pediatric Neurology and Metabolic Medicine, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Elena Schnabel-Besson
- Heidelberg University, Medical Faculty of Heidelberg, Department of Pediatrics I, Division of Pediatric Neurology and Metabolic Medicine, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Oya Kuseyri Hübschmann
- Heidelberg University, Medical Faculty of Heidelberg, Department of Pediatrics I, Division of Pediatric Neurology and Metabolic Medicine, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Friederike Höster
- Heidelberg University, Medical Faculty of Heidelberg, Department of Pediatrics I, Division of Pediatric Neurology and Metabolic Medicine, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Ali Tunҫ Tuncel
- Heidelberg University, Medical Faculty of Heidelberg, Department of Pediatrics I, Division of Pediatric Neurology and Metabolic Medicine, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Stefan Kölker
- Heidelberg University, Medical Faculty of Heidelberg, Department of Pediatrics I, Division of Pediatric Neurology and Metabolic Medicine, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Thomas Opladen
- Heidelberg University, Medical Faculty of Heidelberg, Department of Pediatrics I, Division of Pediatric Neurology and Metabolic Medicine, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
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Meier C, Burns K, Manolikos C, Fatovich D, Bell DA. Hyperammonaemia: review of the pathophysiology, aetiology and investigation. Pathology 2024; 56:763-772. [PMID: 39127541 DOI: 10.1016/j.pathol.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 06/14/2024] [Accepted: 06/18/2024] [Indexed: 08/12/2024]
Abstract
Acute hyperammonaemia is a medical emergency as it can progress to cerebral oedema, seizures, coma and death. Hepatic encephalopathy secondary to cirrhotic disease or portosystemic shunting are relatively well-known causes, but non-cirrhotic aetiologies of acute hyperammonaemia are less well-known, especially in the emergency department. However, an elevated ammonia is not required to make the diagnosis of hepatic encephalopathy. Although measurement of plasma ammonia is recommended for patients with acute, unexplained, altered mental status, as early identification allows early effective management which may prevent irreversible brain damage, there is currently reduced awareness among physicians of the non-cirrhotic aetiologies of acute hyperammonaemia. Furthermore, measurement of ammonia in patients with cirrhosis has been shown to have low sensitivity and specificity, and not to have altered management in the majority of cases; thus, measurement of ammonia is currently not recommended in guidelines for management of hepatic encephalopathy. We sought to describe the pathophysiology of hyperammonaemia and review the non-cirrhotic causes. This was achieved by review of MEDLINE, PubMed and Web of Science databases to include published English literature within the last 20 years. We also present a framework for investigating the acute non-cirrhotic causes of hyperammonaemia to assist both chemical pathologists and clinicians managing these often challenging cases.
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Affiliation(s)
- Ciselle Meier
- The University of Western Australia, Perth, WA, Australia
| | - Kharis Burns
- The University of Western Australia, Perth, WA, Australia; Inborn Errors of Metabolism Service, Department of Endocrinology, Royal Perth Hospital, Perth, WA, Australia
| | - Catherine Manolikos
- Inborn Errors of Metabolism Service, Department of Endocrinology, Royal Perth Hospital, Perth, WA, Australia
| | - Daniel Fatovich
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA, Australia; Emergency Department, Royal Perth Hospital, The University of Western Australia, Perth, WA, Australia
| | - Damon A Bell
- The University of Western Australia, Perth, WA, Australia; Inborn Errors of Metabolism Service, Department of Endocrinology, Royal Perth Hospital, Perth, WA, Australia; PathWest Laboratory Medicine, Department of Biochemistry, Fiona Stanley Hospital Network, Perth, WA, Australia.
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Zielonka M, Kölker S, Garbade SF, Gleich F, Nagamani SCS, Gropman AL, Druck AC, Ramdhouni N, Göde L, Hoffmann GF, Posset R. Severity-adjusted evaluation of initial dialysis on short-term health outcomes in urea cycle disorders. Mol Genet Metab 2024; 143:108566. [PMID: 39299137 DOI: 10.1016/j.ymgme.2024.108566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 08/07/2024] [Accepted: 08/13/2024] [Indexed: 09/22/2024]
Abstract
OBJECTIVE In individuals with urea cycle disorders (UCDs) and neonatal disease onset, extracorporeal detoxification by continuous kidney replacement therapy is considered the therapeutic method of choice in addition to metabolic emergency treatment to resolve hyperammonemic decompensation. However, the indications for the initiation of dialysis are heterogeneously implemented transnationally, thereby hampering our understanding of (optimal) short-term health outcomes. METHODS We performed a retrospective comparative analysis evaluating the therapeutic effects of initial dialysis on survival as well as neurocognitive outcome parameters in individuals with UCDs in comparison to a severity-adjusted non-dialyzed control cohort. Overall, 108 individuals with a severe phenotype of male ornithine transcarbamylase deficiency (mOTC-D), citrullinemia type 1 (CTLN1) and argininosuccinic aciduria (ASA) were investigated by stratification based on a recently established and validated genotype-specific disease prediction model. RESULTS Mortality is associated with the height of initial peak plasma ammonium concentration, but appears to be independent from treatment with initial dialysis in mOTC-D. However, improved survival after initial dialysis was observed in CTLN1, while there was a trend towards improved survival in ASA. In survivors, annual frequency of (subsequent) metabolic decompensations did not differ between the dialyzed and non-dialyzed cohorts. Moreover, treatment with initial dialysis was not associated with improved neurocognitive outcomes. INTERPRETATION The present severity-adjusted comparative analysis reveals that general practice of initial dialysis is neither associated with improved survival in individuals with mOTC-D nor does it differ with regard to the neurocognitive outcome for the investigated UCD subtypes. However, initial dialysis might potentially prove beneficial for survival in CTLN1 and ASA. CLINICAL TRIAL REGISTRATION The UCDC database is recorded at the US National Library of Medicine (https://clinicaltrials.gov).
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Affiliation(s)
- Matthias Zielonka
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany.
| | - Stefan Kölker
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Sven F Garbade
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Florian Gleich
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Sandesh C S Nagamani
- Department of Molecular and Human Genetics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Andrea L Gropman
- Children's National Health System and The George Washington School of Medicine, Washington, DC, USA
| | - Ann-Catrin Druck
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Nesrine Ramdhouni
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Laura Göde
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Georg F Hoffmann
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Roland Posset
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany.
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Posset R, Garbade SF, Gleich F, Nagamani SCS, Gropman AL, Epp F, Ramdhouni N, Druck AC, Hoffmann GF, Kölker S, Zielonka M. Impact of supplementation with L-citrulline/arginine after liver transplantation in individuals with Urea Cycle Disorders. Mol Genet Metab 2024; 141:108112. [PMID: 38301530 DOI: 10.1016/j.ymgme.2023.108112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/06/2023] [Accepted: 12/06/2023] [Indexed: 02/03/2024]
Abstract
OBJECTIVE Liver transplantation (LTx) is an intervention when medical management is not sufficiently preventing individuals with urea cycle disorders (UCDs) from the occurrence of hyperammonemic events. Supplementation with L-citrulline/arginine is regularly performed prior to LTx to support ureagenesis and is often continued after the intervention. However, systematic studies assessing the impact of long-term L-citrulline/arginine supplementation in individuals who have undergone LTx is lacking to date. METHODS Using longitudinal data collected systematically, a comparative analysis was carried out by studying the effects of long-term L-citrulline/arginine supplementation vs. no supplementation on health-related outcome parameters (i.e., anthropometric, neurological, and cognitive outcomes) in individuals with UCDs who have undergone LTx. Altogether, 52 individuals with male ornithine transcarbamylase deficiency, citrullinemia type 1 and argininosuccinic aciduria and a pre-transplant "severe" disease course who have undergone LTx were investigated by using recently established and validated genotype-specific in vitro enzyme activities. RESULTS Long-term supplementation of individuals with L-citrulline/arginine who have undergone LTx (n = 16) does neither appear to alter anthropometric nor neurocognitive endpoints when compared to their severity-adjusted counterparts that were not supplemented (n = 36) after LTx with mean observation periods between four to five years. Moreover, supplementation with L-citrulline/arginine was not associated with an increase of disease-specific plasma arithmetic mean values for the respective amino acids when compared to the non-supplemented control cohort. CONCLUSION Although supplementation with L-citrulline/arginine is often continued after LTx, this pilot study does neither identify altered long-term anthropometric or neurocognitive health-related outcomes nor does it find an adequate biochemical response as reflected by the unaltered plasma arithmetic mean values for L-citrulline or L-arginine. Further prospective analyses in larger samples and even longer observation periods will provide more insight into the usefulness of long-term supplementation with L-citrulline/arginine for individuals with UCDs who have undergone LTx.
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Affiliation(s)
- Roland Posset
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany.
| | - Sven F Garbade
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Florian Gleich
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Sandesh C S Nagamani
- Department of Molecular and Human Genetics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Andrea L Gropman
- Children's National Health System and The George Washington School of Medicine, Washington, DC, USA
| | - Friederike Epp
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Nesrine Ramdhouni
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Ann-Catrin Druck
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Georg F Hoffmann
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Stefan Kölker
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Matthias Zielonka
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany.
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Quaglia A, Roberts EA, Torbenson M. Developmental and Inherited Liver Disease. MACSWEEN'S PATHOLOGY OF THE LIVER 2024:122-294. [DOI: 10.1016/b978-0-7020-8228-3.00003-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2025]
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Posset R, Zielonka M, Gleich F, Garbade SF, Hoffmann GF, Kölker S. The challenge of understanding and predicting phenotypic diversity in urea cycle disorders. J Inherit Metab Dis 2023; 46:1007-1016. [PMID: 37702610 DOI: 10.1002/jimd.12678] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/31/2023] [Accepted: 09/05/2023] [Indexed: 09/14/2023]
Abstract
The Urea Cycle Disorders Consortium (UCDC) and the European registry and network for Intoxication type Metabolic Diseases (E-IMD) are the worldwide largest databases for individuals with urea cycle disorders (UCDs) comprising longitudinal data from more than 1100 individuals with an overall long-term follow-up of approximately 25 years. However, heterogeneity of the clinical phenotype as well as different diagnostic and therapeutic strategies hamper our understanding on the predictors of phenotypic diversity and the impact of disease-immanent and interventional variables (e.g., diagnostic and therapeutic interventions) on the long-term outcome. A new strategy using combined and comparative data analyses helped overcome this challenge. This review presents the mechanisms and relevant principles that are necessary for the identification of meaningful clinical associations by combining data from different data sources, and serves as a blueprint for future analyses of rare disease registries.
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Affiliation(s)
- Roland Posset
- Division of Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Zielonka
- Division of Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
- Heidelberg Research Center for Molecular Medicine (HRCMM), Heidelberg, Germany
| | - Florian Gleich
- Division of Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Sven F Garbade
- Division of Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Georg F Hoffmann
- Division of Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Kölker
- Division of Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
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Kho J, Polak U, Jiang MM, Odom JD, Hunter JV, Ali SM, Burrage LC, Nagamani SC, Pautler RG, Thompson HP, Urayama A, Jin Z, Lee B. Argininosuccinate lyase deficiency causes blood-brain barrier disruption via nitric oxide-mediated dysregulation of claudin expression. JCI Insight 2023; 8:e168475. [PMID: 37490345 PMCID: PMC10544197 DOI: 10.1172/jci.insight.168475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 07/19/2023] [Indexed: 07/27/2023] Open
Abstract
Nitric oxide (NO) is a critical signaling molecule that has been implicated in the pathogenesis of neurocognitive diseases. Both excessive and insufficient NO production have been linked to pathology. Previously, we have shown that argininosuccinate lyase deficiency (ASLD) is a novel model system to investigate cell-autonomous, nitric oxide synthase-dependent NO deficiency. Humans with ASLD are at increased risk for developing hyperammonemia due to a block in ureagenesis. However, natural history studies have shown that individuals with ASLD have multisystem disease including neurocognitive deficits that can be independent of ammonia. Here, using ASLD as a model of NO deficiency, we investigated the effects of NO on brain endothelial cells in vitro and the blood-brain barrier (BBB) in vivo. Knockdown of ASL in human brain microvascular endothelial cells (HBMECs) led to decreased transendothelial electrical resistance, indicative of increased cell permeability. Mechanistically, treatment with an NO donor or inhibition of Claudin-1 improved barrier integrity in ASL-deficient HBMECs. Furthermore, in vivo assessment of a hypomorphic mouse model of ASLD showed increased BBB leakage, which was partially rescued by NO supplementation. Our results suggest that ASL-mediated NO synthesis is required for proper maintenance of brain microvascular endothelial cell functions as well as BBB integrity.
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Affiliation(s)
- Jordan Kho
- Department of Molecular and Human Genetics and
| | | | | | | | - Jill V. Hunter
- Department of Radiology, Baylor College of Medicine, Houston, Texas, USA
- Texas Children’s Hospital, Houston, Texas, USA
| | | | - Lindsay C. Burrage
- Department of Molecular and Human Genetics and
- Texas Children’s Hospital, Houston, Texas, USA
| | - Sandesh C.S. Nagamani
- Department of Molecular and Human Genetics and
- Texas Children’s Hospital, Houston, Texas, USA
| | - Robia G. Pautler
- Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, Texas, USA
| | - Hannah P. Thompson
- Department of Neurology, University of Texas Health Science Center, Houston, Texas, USA
| | - Akihiko Urayama
- Department of Neurology, University of Texas Health Science Center, Houston, Texas, USA
| | - Zixue Jin
- Department of Molecular and Human Genetics and
| | - Brendan Lee
- Department of Molecular and Human Genetics and
- Texas Children’s Hospital, Houston, Texas, USA
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Ibrahim MS, Gold JI, Woodall A, Yilmaz BS, Gissen P, Stepien KM. Diagnostic and Management Issues in Patients with Late-Onset Ornithine Transcarbamylase Deficiency. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1368. [PMID: 37628367 PMCID: PMC10453542 DOI: 10.3390/children10081368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 07/24/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023]
Abstract
Ornithine transcarbamylase deficiency (OTCD) is the most common inherited disorder of the urea cycle and, in general, is transmitted as an X-linked recessive trait. Defects in the OTC gene cause an impairment in ureagenesis, resulting in hyperammonemia, which is a direct cause of brain damage and death. Patients with late-onset OTCD can develop symptoms from infancy to later childhood, adolescence or adulthood. Clinical manifestations of adults with OTCD vary in acuity. Clinical symptoms can be aggravated by metabolic stressors or the presence of a catabolic state, or due to increased demands upon the urea. A prompt diagnosis and relevant biochemical and genetic investigations allow the rapid introduction of the right treatment and prevent long-term complications and mortality. This narrative review outlines challenges in diagnosing and managing patients with late-onset OTCD.
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Affiliation(s)
- Majitha Seyed Ibrahim
- Department of Chemical Pathology, Teaching Hospital Batticaloa, Batticaloa 30000, Sri Lanka
| | - Jessica I. Gold
- Division of Human Genetics, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Alison Woodall
- Adult Inherited Metabolic Diseases, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
| | - Berna Seker Yilmaz
- Great Ormond Street Institute of Child Health, University College London, London WC1E 6BT, UK
| | - Paul Gissen
- Great Ormond Street Institute of Child Health, University College London, London WC1E 6BT, UK
- Department of Paediatric Metabolic Medicine, Great Ormond Street Hospital for Children NHS Trust, London WC1N 3JH, UK
- National Institute of Health Research, Great Ormond Street Biomedical Research Centre, London WC1N 1EH, UK
| | - Karolina M. Stepien
- Adult Inherited Metabolic Diseases, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
- Division of Cardiovascular Sciences, University of Manchester, Manchester M13 9PL, UK
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Wang S, Chen J, Zhu X, Huang T, Xu H, Ying G, Qian H, Lin W, Tung Y, Khan KU, Guo H, Zheng G, Lu H, Zhang G. Clinical and genetic analysis of a case of late onset carbamoyl phosphate synthase I deficiency caused by CPS1 mutation and literature review. BMC Med Genomics 2023; 16:145. [PMID: 37365635 DOI: 10.1186/s12920-023-01569-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 06/02/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Carbamoyl phosphate synthetase I defect (CPS1D) is a rare disease with clinical case reports mainly in early neonates or adults, with few reports of first onset in late neonatal to childhood. We studied the clinical and genotypic characteristics of children with childhood onset CPS1D caused by two loci mutations (one of these is a rarely reported non-frame shift mutation) in the CPS1. CASE PRESENTATION We present a rare case of adolescent-onset CPS1D that had been misdiagnosed due to atypical clinical features, and further investigations revealed severe hyperammonemia (287µmol/L; reference range 11.2 ~ 48.2umol/L). MRI of the brain showed diffuse white matter lesions. Blood genetic metabolic screening showed elevated blood alanine (757.06umol/L; reference range 148.8 ~ 739.74umol/L) and decreased blood citrulline (4.26umol/L; reference range 5.45 ~ 36.77umol/L). Urine metabolic screening showed normal whey acids and uracil. Whole-exome sequencing revealed compound heterozygous mutations in the CPS1, a missense mutation (c.1145 C > T) and an unreported de novo non-frame shift mutation (c.4080_c.4091delAGGCATCCTGAT), respectively, which provided a clinical diagnosis. CONCLUSION A comprehensive description of the clinical and genetic features of this patient, who has a rare age of onset and a relatively atypical clinical presentation, will facilitate the early diagnosis and management of this type of late onset CPS1D and reduce misdiagnosis, thus helping to reduce mortality and improve prognosis. It also provides a preliminary understanding of the relationship between genotype and phenotype, based on a summary of previous studies, which reminds us that it may help to explore the pathogenesis of the disease and contribute to genetic counselling and prenatal diagnosis.
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Affiliation(s)
- Shangyu Wang
- Department of Neurology, Children's Hospital of Nanjing Medical University, No.72 Guangzhou Road, Nanjing, Jiangsu, China
| | | | - Xiaoqi Zhu
- Nanjing Medical University, Nanjing, China
| | - Tingting Huang
- Department of Neurology, Children's Hospital of Nanjing Medical University, No.72 Guangzhou Road, Nanjing, Jiangsu, China
| | - Haifeng Xu
- Department of Neurology, Children's Hospital of Nanjing Medical University, No.72 Guangzhou Road, Nanjing, Jiangsu, China
| | - Guohuan Ying
- Department of Neurology, Children's Hospital of Nanjing Medical University, No.72 Guangzhou Road, Nanjing, Jiangsu, China
| | - Hao Qian
- Department of Neurology, Children's Hospital of Nanjing Medical University, No.72 Guangzhou Road, Nanjing, Jiangsu, China
| | - Wenxin Lin
- Department of Neurology, Children's Hospital of Nanjing Medical University, No.72 Guangzhou Road, Nanjing, Jiangsu, China
| | - Yiehen Tung
- Department of Neurology, Children's Hospital of Nanjing Medical University, No.72 Guangzhou Road, Nanjing, Jiangsu, China
| | - Kaleem Ullah Khan
- Department of Neurology, Children's Hospital of Nanjing Medical University, No.72 Guangzhou Road, Nanjing, Jiangsu, China
| | - Hu Guo
- Department of Neurology, Children's Hospital of Nanjing Medical University, No.72 Guangzhou Road, Nanjing, Jiangsu, China
| | - Guo Zheng
- Department of Neurology, Children's Hospital of Nanjing Medical University, No.72 Guangzhou Road, Nanjing, Jiangsu, China
| | - Haiying Lu
- Department of Neurology, Children's Hospital of Nanjing Medical University, No.72 Guangzhou Road, Nanjing, Jiangsu, China
| | - Gang Zhang
- Department of Neurology, Children's Hospital of Nanjing Medical University, No.72 Guangzhou Road, Nanjing, Jiangsu, China.
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Shakerdi L, Ryan A. Drug-induced hyperammonaemia. J Clin Pathol 2023:jcp-2022-208644. [PMID: 37164630 DOI: 10.1136/jcp-2022-208644] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 04/28/2023] [Indexed: 05/12/2023]
Abstract
Hyperammonaemia (HA) as a consequence of numerous primary or secondary causes, gives rise to clinical manifestations due to its toxic effects on the brain. The neurological consequences broadly reflect the ammonia level, duration and age, with paediatric patients being more susceptible. Drug-induced HA may arise due to either decreased ammonia elimination or increased production. This is associated most frequently with use of valproate and presents a dilemma between ongoing therapeutic need, toxicity and the possibility of an alternative cause. As there is no specific test for drug-induced HA, prompt discussion with a metabolic physician is recommended, as the neurotoxic effects are time-dependent. Specific guidelines for managing drug-induced HA have yet to be published and hence the treatment approach outlined in this review reflects that outlined in relevant urea cycle disorder guidelines.
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Affiliation(s)
- Loai Shakerdi
- National Centre for Inherited Metabolic Disorders, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Aidan Ryan
- Chemical Pathology, Cork University Hospital Biochemistry Laboratory, Cork, Ireland
- Pathology, University College Cork College of Medicine and Health, Cork, Ireland
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11
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Lo RS, Cromie GA, Tang M, Teng K, Owens K, Sirr A, Kutz JN, Morizono H, Caldovic L, Ah Mew N, Gropman A, Dudley AM. The functional impact of 1,570 individual amino acid substitutions in human OTC. Am J Hum Genet 2023; 110:863-879. [PMID: 37146589 PMCID: PMC10183466 DOI: 10.1016/j.ajhg.2023.03.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/30/2023] [Indexed: 05/07/2023] Open
Abstract
Deleterious mutations in the X-linked gene encoding ornithine transcarbamylase (OTC) cause the most common urea cycle disorder, OTC deficiency. This rare but highly actionable disease can present with severe neonatal onset in males or with later onset in either sex. Individuals with neonatal onset appear normal at birth but rapidly develop hyperammonemia, which can progress to cerebral edema, coma, and death, outcomes ameliorated by rapid diagnosis and treatment. Here, we develop a high-throughput functional assay for human OTC and individually measure the impact of 1,570 variants, 84% of all SNV-accessible missense mutations. Comparison to existing clinical significance calls, demonstrated that our assay distinguishes known benign from pathogenic variants and variants with neonatal onset from late-onset disease presentation. This functional stratification allowed us to identify score ranges corresponding to clinically relevant levels of impairment of OTC activity. Examining the results of our assay in the context of protein structure further allowed us to identify a 13 amino acid domain, the SMG loop, whose function appears to be required in human cells but not in yeast. Finally, inclusion of our data as PS3 evidence under the current ACMG guidelines, in a pilot reclassification of 34 variants with complete loss of activity, would change the classification of 22 from variants of unknown significance to clinically actionable likely pathogenic variants. These results illustrate how large-scale functional assays are especially powerful when applied to rare genetic diseases.
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Affiliation(s)
- Russell S Lo
- Pacific Northwest Research Institute, Seattle, WA, USA
| | | | - Michelle Tang
- Pacific Northwest Research Institute, Seattle, WA, USA
| | - Kevin Teng
- Pacific Northwest Research Institute, Seattle, WA, USA
| | - Katherine Owens
- Pacific Northwest Research Institute, Seattle, WA, USA; Department of Applied Mathematics, University of Washington, Seattle, WA, USA
| | - Amy Sirr
- Pacific Northwest Research Institute, Seattle, WA, USA
| | - J Nathan Kutz
- Department of Applied Mathematics, University of Washington, Seattle, WA, USA
| | - Hiroki Morizono
- Center for Genetic Medicine Research, Children's National Research Institute, Children's National Hospital, Washington, DC, USA; Department of Genomics and Precision Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Ljubica Caldovic
- Center for Genetic Medicine Research, Children's National Research Institute, Children's National Hospital, Washington, DC, USA; Department of Genomics and Precision Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Nicholas Ah Mew
- Center for Genetic Medicine Research, Children's National Research Institute, Children's National Hospital, Washington, DC, USA; Department of Genomics and Precision Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Andrea Gropman
- Center for Genetic Medicine Research, Children's National Research Institute, Children's National Hospital, Washington, DC, USA; Department of Genomics and Precision Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA; Department of Neurology, Division of Neurogenetics and Neurodevelopmental Disabilities, Children's National Hospital, Washington, DC, USA; Center for Neuroscience Research, Children's National Research Institute, Children's National Hospital, Washington, DC, USA
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12
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Hyperammonemia in a pregnant woman with citrullinemia type I: a case report and literature review. BMC Pregnancy Childbirth 2022; 22:950. [PMID: 36536326 PMCID: PMC9762101 DOI: 10.1186/s12884-022-05298-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 12/09/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Citrullinemia type I (CTLN1) is a rare urea cycle disorder (UCD) with few adult cases described so far. Diagnosis of late-onset CTLN1 is difficult, and delayed treatment may increase the risk of severe hyperammonemia. Pregnancy is an important risk factor for women with CTLN1. However, the clinical manifestations of CTLN1 in a pregnant woman may be mistaken for pregnancy side effects and ultimately delay a timely diagnosis. CASE PRESENTATION A 34-year-old woman developed vomiting and disturbance of consciousness after 12 weeks of gestation. A blood test showed hyperammonemia (454 μg/dL) with normal liver function tests. She fell into a deep coma, and her serum ammonia level increased to 800 μg/dL. Continuous renal replacement therapy (CRRT) was administered as a diagnostic treatment for UCD and serum ammonia. This patient's case was complicated by co-infection; her dependents decided to withdraw life support and the patient died. She was diagnosed with CTLN1 by analyses of plasma amino acids, urinary orotic acid, and second-generation gene sequencing. DISCUSSION AND CONCLUSION When a patient displays symptoms of emesis and disturbance of consciousness in early pregnancy, blood ammonia should be monitored, and UCD should be considered, particularly for patients with hyperammonemia in the absence of severe liver function abnormalities.
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13
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Bin Sawad A, Jackimiec J, Bechter M, Trucillo A, Lindsley K, Bhagat A, Uyei J, Diaz GA. Epidemiology, methods of diagnosis, and clinical management of patients with arginase 1 deficiency (ARG1-D): A systematic review. Mol Genet Metab 2022; 137:153-163. [PMID: 36049366 DOI: 10.1016/j.ymgme.2022.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/18/2022] [Accepted: 08/20/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Arginase 1 Deficiency (ARG1-D) is a rare, progressive, metabolic disorder that is characterized by devastating manifestations driven by elevated plasma arginine levels. It typically presents in early childhood with spasticity (predominately affecting the lower limbs), mobility impairment, seizures, developmental delay, and intellectual disability. This systematic review aims to identify and describe the published evidence outlining the epidemiology, diagnosis methods, measures of disease progression, clinical management, and outcomes for ARG1-D patients. METHODS A comprehensive literature search across multiple databases such as MEDLINE, Embase, and a review of clinical studies in ClinicalTrials.gov (with results reported) was carried out per PRISMA guidelines on 20 April 2020 with no date restriction. Pre-defined eligibility criteria were used to identify studies with data specific to patients with ARG1-D. Two independent reviewers screened records and extracted data from included studies. Quality was assessed using the modified Newcastle-Ottawa Scale for non-comparative studies. RESULTS Overall, 55 records reporting 40 completed studies and 3 ongoing studies were included. Ten studies reported the prevalence of ARG1-D in the general population, with a median of 1 in 1,000,000. Frequently reported diagnostic methods included genetic testing, plasma arginine levels, and red blood cell arginase activity. However, routine newborn screening is not universally available, and lack of disease awareness may prevent early diagnosis or lead to misdiagnosis, as the disease has overlapping symptomology with other diseases, such as cerebral palsy. Common manifestations reported at time of diagnosis and assessed for disease progression included spasticity (predominately affecting the lower limbs), mobility impairment, developmental delay, intellectual disability, and seizures. Severe dietary protein restriction, essential amino acid supplementation, and nitrogen scavenger administration were the most commonly reported treatments among patients with ARG1-D. Only a few studies reported meaningful clinical outcomes of these interventions on intellectual disability, motor function and adaptive behavior assessment, hospitalization, or death. The overall quality of included studies was assessed as good according to the Newcastle-Ottawa Scale. CONCLUSIONS Although ARG1-D is a rare disease, published evidence demonstrates a high burden of disease for patients. The current standard of care is ineffective at preventing disease progression. There remains a clear need for new treatment options as well as improved access to diagnostics and disease awareness to detect and initiate treatment before the onset of clinical manifestations to potentially enable more normal development, improve symptomatology, or prevent disease progression.
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Affiliation(s)
| | | | | | | | | | | | | | - George A Diaz
- Division of Medical Genetics and Genomics in the Department of Genetics and Genomic Sciences at the Icahn School of Medicine at Mount Sinai, New York, NY, USA
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14
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Kölker S, Gleich F, Mütze U, Opladen T. Rare Disease Registries Are Key to Evidence-Based Personalized Medicine: Highlighting the European Experience. Front Endocrinol (Lausanne) 2022; 13:832063. [PMID: 35317224 PMCID: PMC8934440 DOI: 10.3389/fendo.2022.832063] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 01/31/2022] [Indexed: 12/24/2022] Open
Abstract
Rare diseases, such as inherited metabolic diseases, have been identified as a health priority within the European Union more than 20 years ago and have become an integral part of EU health programs and European Reference Networks. Having the potential to pool data, to achieve sufficient sample size, to overcome the knowledge gap on rare diseases and to foster epidemiological and clinical research, patient registries are recognized as key instruments to evidence-based medicine for individuals with rare diseases. Patient registries can be used for multiple purposes, such as (1) describing the natural history and phenotypic diversity of rare diseases, (2) improving case definition and indication to treat, (3) identifying strategies for risk stratification and early prediction of disease severity (4), evaluating the impact of preventive, diagnostic, and therapeutic strategies on individual health, health economics, and the society, and (5) informing guideline development and policy makers. In contrast to clinical trials, patient registries aim to gather real-world evidence and to achieve generalizable results based on patient cohorts with a broad phenotypic spectrum. In order to develop a consistent and sustained framework for rare disease registries, uniform core principles have been formulated and have been formalized through the European Rare Disease Registration Infrastructure. Adherence to these core principles and compliance with the European general data protection regulations ensures that data collected and stored in patient registries can be exchanged and pooled in a protected environment. To illustrate the benefits and limitations of patient registries on rare disease research this review focuses on inherited metabolic diseases.
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15
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Kido J, Matsumoto S, Takeshita E, Hayasaka C, Yamada K, Kagawa J, Nakajima Y, Ito T, Iijima H, Endo F, Nakamura K. Current status of surviving patients with arginase 1 deficiency in Japan. Mol Genet Metab Rep 2021; 29:100805. [PMID: 34646736 PMCID: PMC8495172 DOI: 10.1016/j.ymgmr.2021.100805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/20/2021] [Accepted: 09/22/2021] [Indexed: 12/14/2022] Open
Abstract
Arginase 1 (ARG1) deficiency is a rare urea cycle disorder (UCD), with an estimated frequency of 1 per 2,200,000 births in Japan. Patients with ARG1 deficiency develop symptoms in late infancy or pre-school age with progressive neurological manifestations and sometimes present with severe hepatic disease. We previously investigated the status of UCDs in Japan; however, only one patient was identified as having ARG1 deficiency. Therefore, we aimed to investigate the current status of patients with ARG1 deficiency in 2018–2021 because almost 10 years have passed since the previous study. We present the disease history, clinical outcome, and treatment of five surviving patients with ARG1 deficiency and discuss the features of ARG1 deficiency in Japan. We found that clinicians often face difficulty in diagnosing ARG1 deficiency at the early stage of onset because of interpatient variability in onset time and clinical manifestations. Blood L-arginine and guanidino compounds were considered to be the major factors causing adverse neurodevelopmental outcomes. Therefore, early detection and intervention of ARG1 deficiency is essential for improved neurodevelopmental outcomes. Liver transplantation has been considered an effective treatment option that can dramatically improve the quality of life of patients, prior to the neurological manifestation of symptoms caused by ARG1 deficiency.
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Affiliation(s)
- Jun Kido
- Department of Pediatrics, Faculty of Life Sciences, Kumamoto University, Kumamoto City, Kumamoto, Japan
| | - Shirou Matsumoto
- Department of Pediatrics, Faculty of Life Sciences, Kumamoto University, Kumamoto City, Kumamoto, Japan
| | - Eiko Takeshita
- Department of Pediatrics, Yanagawa Institute for Developmental Disabilities, International University of Health and Welfare, Yanagawa City, Fukuoka, Japan
| | | | - Keitaro Yamada
- Department of Pediatric Neurology, Aichi Developmental Disability Center Central Hospital, Kasugai City, Aichi, Japan
| | - Jiro Kagawa
- Department of Pediatrics, Fujieda Municipal General Hospital, Fujieda City, Shizuoka, Japan
| | - Yoko Nakajima
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake City, Aichi, Japan
| | - Tetsuya Ito
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake City, Aichi, Japan
| | - Hiroyuki Iijima
- Department of General Pediatrics & Interdisciplinary Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Fumio Endo
- Department of Pediatrics, Faculty of Life Sciences, Kumamoto University, Kumamoto City, Kumamoto, Japan
| | - Kimitoshi Nakamura
- Department of Pediatrics, Faculty of Life Sciences, Kumamoto University, Kumamoto City, Kumamoto, Japan
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16
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Toquet S, Spodenkiewicz M, Douillard C, Maillot F, Arnoux JB, Damaj L, Odent S, Moreau C, Redonnet-Vernhet I, Mesli S, Servais A, Noel E, Charriere S, Rigalleau V, Lavigne C, Kaphan E, Roubertie A, Besson G, Bigot A, Servettaz A, Mochel F, Garnotel R. Adult-onset diagnosis of urea cycle disorders: Results of a French cohort of 71 patients. J Inherit Metab Dis 2021; 44:1199-1214. [PMID: 34014557 DOI: 10.1002/jimd.12403] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 05/14/2021] [Accepted: 05/18/2021] [Indexed: 12/19/2022]
Abstract
Urea cycle disorders (UCD) are rare diseases that usually affect neonates or young children. During decompensations, hyperammonemia is neurotoxic, leading to severe symptoms and even coma and death if not treated rapidly. The aim was to describe a cohort of patients with adult onset of UCDs in a multicentric, retrospective and descriptive study of French adult patients with a diagnosis after 16 years of age of UCDs due to a deficiency in one of the 6 enzymes (arginase, ASL, ASS, CPS1, NAGS, OTC) or the two transporters (ORNT1 or citrin). Seventy-one patients were included (68% female, 32% male). The diagnosis was made in the context of (a) a metabolic decompensation (42%), (b) family history (55%), or (c) chronic symptoms (3%). The median age at diagnosis was 33 years (range 16-86). Eighty-nine percent of patients were diagnosed with OTC deficiency, 7% CPS1 deficiency, 3% HHH syndrome and 1% argininosuccinic aciduria. For those diagnosed during decompensations (including 23 OTC cases, mostly female), 89% required an admission in intensive care units. Seven deaths were attributed to UCD-6 decompensations and 1 epilepsy secondary to inaugural decompensation. This is the largest cohort of UCDs diagnosed in adulthood, which confirms the triad of neurological, gastrointestinal and psychiatric symptoms during hyperammonemic decompensations. We stress that females with OTC deficiency can be symptomatic. With 10% of deaths in this cohort, UCDs in adults remain a life-threatening condition. Physicians working in adult care must be aware of late-onset presentations given the implications for patients and their families.
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Affiliation(s)
- Ségolène Toquet
- Service de Médecine Interne, Hôpital Robert Debré, CHU Reims, France
| | | | - Claire Douillard
- Service d'Endocrinologie et Métabolismes, Hôpital Claude Huriez, Centre de Référence des Maladies Héréditaires du métabolisme, CHU Lille, France
| | - François Maillot
- Service de Médecine Interne, Hôpital Bretonneau, CHRU de Tours, France
| | - Jean-Baptiste Arnoux
- Centre de Référence des Maladies Héréditaires du Métabolisme, Hôpital Necker-Enfants Malades, CHU Paris, France
| | - Lena Damaj
- Service de Pédiatrie, CHU Hôpital Sud, Rennes, France
| | - Sylvie Odent
- Service de Génétique Clinique, CHU Hôpital Sud, Rennes, France
| | - Caroline Moreau
- Service de Biochimie et Toxicologie, CHU Pontchaillou, Rennes, France
| | | | - Samir Mesli
- Laboratoire de Biochimie, Hôpital Pellegrin, CHU Bordeaux, France
| | - Aude Servais
- Service de Néphrologie adulte, Hôpital Necker-Enfants Malades, CHU Paris, France
| | - Esther Noel
- Service de Médecine Interne, Hôpital Universitaire de Strasbourg, CHRU Strasbourg, France
| | - Sybill Charriere
- Fédération d'endocrinologie, maladies métaboliques, diabète et nutrition, Hôpital Louis Pradel, Centre de Référence des Maladies Héréditaires du Métabolisme, Bron, France
| | | | | | - Elsa Kaphan
- Pôle de Neurosciences Cliniques, CHU Timone, AP-HM, Marseille, France
| | - Agathe Roubertie
- Département de neuropédiatrie, Hôpital Gui de Chauliac, CHU Montpellier, France
| | | | - Adrien Bigot
- Service de Médecine Interne, Hôpital Bretonneau, CHRU de Tours, France
| | - Amélie Servettaz
- Service de Médecine Interne, Hôpital Robert Debré, CHU Reims, France
| | - Fanny Mochel
- Département de génétique, Hôpital Pitié-Salpêtrière, CHU Paris, France
| | - Roselyne Garnotel
- Laboratoire de Biochimie-Pharmacologie-Toxicologie, CHU Reims, France
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17
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Gobin-Limballe S, Ottolenghi C, Reyal F, Arnoux JB, Magen M, Simon M, Brassier A, Jabot-Hanin F, Lonlay PD, Pontoizeau C, Guirat M, Rio M, Gesny R, Gigarel N, Royer G, Steffann J, Munnich A, Bonnefont JP. OTC deficiency in females: Phenotype-genotype correlation based on a 130-family cohort. J Inherit Metab Dis 2021; 44:1235-1247. [PMID: 34014569 DOI: 10.1002/jimd.12404] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 05/14/2021] [Accepted: 05/18/2021] [Indexed: 12/30/2022]
Abstract
OTC deficiency, an inherited urea cycle disorder, is caused by mutations in the X-linked OTC gene. Phenotype-genotype correlations are well understood in males but still poorly known in females. Taking advantage of a cohort of 130 families (289 females), we assessed the relative contribution of OTC enzyme activity, X chromosome inactivation, and OTC gene sequencing to genetic counseling in heterozygous females. Twenty two percent of the heterozygous females were clinically affected, with episodic (11%), chronic (7.5%), or neonatal forms of the disease (3.5%). Overall mortality rate was 4%. OTC activity, ranging from 0% to 60%, did not correlate with phenotype at the individual level. Analysis of multiple samples from 4 mutant livers showed intra-hepatic variability of OTC activity and X inactivation profile (range of variability: 30% and 20%, respectively) without correlation between both parameters for 3 of the 4 livers. Ninety disease-causing variants were found, 27 of which were novel. Mutations were classified as "mild" or "severe," based on male phenotypes and/or in silico prediction. In our cohort, a serious disease occurred in 32% of females with a severe mutation, compared to 4% in females with a mild mutation (odds ratio = 1.365; P = 1.6e-06). These data should help prenatal diagnosis for heterozygous females and genetic counseling after fortuitous findings of OTC variants in pangenomic sequencing.
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Affiliation(s)
| | - Chris Ottolenghi
- Metabolomic and Proteomic Biochemistry Department, Necker Hospital, APHP Centre- Paris University, Paris, France
- INSERM UMR1163, Institut Imagine, Paris University, Paris, France
| | - Fabien Reyal
- Molecular Genetics Department, Necker Hospital, APHP Centre-Paris University, Paris, France
- Breast Gynecologic Cancer Reconstructive Team, Institut Curie, Paris University, Paris, France
| | - Jean-Baptiste Arnoux
- Inherited Metabolic Disease Department and National Reference Centre for Inherited Metabolic diseases, Necker Hospital, APHP Centre-Paris University, Paris, France
- INSERM U1151, INEM, Paris University, Paris, France
| | - Maryse Magen
- Molecular Genetics Department, Necker Hospital, APHP Centre-Paris University, Paris, France
| | - Marie Simon
- Molecular Genetics Department, Necker Hospital, APHP Centre-Paris University, Paris, France
| | - Anaïs Brassier
- Inherited Metabolic Disease Department and National Reference Centre for Inherited Metabolic diseases, Necker Hospital, APHP Centre-Paris University, Paris, France
- INSERM U1151, INEM, Paris University, Paris, France
| | - Fabienne Jabot-Hanin
- Bioinformatics Platform, Paris University, INSERM UMR1163, Institut Imagine, Paris, France
- Structure Federative de Recherche Necker, INSERM US24/CNRS UMS3633, Paris, France
| | - Pascale De Lonlay
- Inherited Metabolic Disease Department and National Reference Centre for Inherited Metabolic diseases, Necker Hospital, APHP Centre-Paris University, Paris, France
- INSERM U1151, INEM, Paris University, Paris, France
| | - Clement Pontoizeau
- Metabolomic and Proteomic Biochemistry Department, Necker Hospital, APHP Centre- Paris University, Paris, France
- INSERM UMR1163, Institut Imagine, Paris University, Paris, France
| | - Manel Guirat
- Molecular Genetics Department, Necker Hospital, APHP Centre-Paris University, Paris, France
| | - Marlene Rio
- Clinical Genetics Department, Necker Hospital, APHP Centre-Paris University, Paris, France
| | - Roselyne Gesny
- Molecular Genetics Department, Necker Hospital, APHP Centre-Paris University, Paris, France
| | - Nadine Gigarel
- Molecular Genetics Department, Necker Hospital, APHP Centre-Paris University, Paris, France
| | - Ghislaine Royer
- Molecular Genetics Department, Necker Hospital, APHP Centre-Paris University, Paris, France
| | - Julie Steffann
- Molecular Genetics Department, Necker Hospital, APHP Centre-Paris University, Paris, France
- INSERM UMR1163, Institut Imagine, Paris University, Paris, France
| | - Arnold Munnich
- INSERM UMR1163, Institut Imagine, Paris University, Paris, France
- Clinical Genetics Department, Necker Hospital, APHP Centre-Paris University, Paris, France
| | - Jean-Paul Bonnefont
- Molecular Genetics Department, Necker Hospital, APHP Centre-Paris University, Paris, France
- INSERM UMR1163, Institut Imagine, Paris University, Paris, France
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18
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Kido J, Matsumoto S, Häberle J, Nakajima Y, Wada Y, Mochizuki N, Murayama K, Lee T, Mochizuki H, Watanabe Y, Horikawa R, Kasahara M, Nakamura K. Long-term outcome of urea cycle disorders: Report from a nationwide study in Japan. J Inherit Metab Dis 2021; 44:826-837. [PMID: 33840128 DOI: 10.1002/jimd.12384] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 12/20/2022]
Abstract
Urea cycle disorders (UCDs) are inherited metabolic disorders with impaired nitrogen detoxification caused by defects in urea cycle enzymes. They often manifest with hyperammonemic attacks resulting in significant morbidity or death. We performed a nationwide questionnaire-based study between January 2000 and March 2018 to document all UCDs in Japan, including diagnoses, treatments, and outcomes. A total of 229 patients with UCDs were enrolled in this study: 73 males and 53 females with ornithine transcarbamylase deficiency (OTCD), 33 patients with carbamoylphosphate synthetase 1 deficiency, 48 with argininosuccinate synthetase deficiency, 14 with argininosuccinate lyase deficiency, and 8 with arginase deficiency. Survival rates at 20 years of age of male and female patients with late-onset OTCD were 100% and 97.7%, respectively. Blood ammonia levels and time of onset had a significant impact on the neurodevelopmental outcome (P < .001 and P = .028, respectively). Hemodialysis and liver transplantation did not prevent poor neurodevelopmental outcomes. While treatment including medication, hemodialysis, and liver transplantation may aid in decreasing blood ammonia and/or preventing severe hyperammonemia, a blood ammonia level ≥ 360 μmol/L was found to be a significant indicator for a poor neurodevelopmental outcome. In conclusion, although current therapy for UCDs has advanced and helped saving lives, patients with blood ammonia levels ≥ 360 μmol/L at onset often have impaired neurodevelopmental outcomes. Novel neuroprotective measures should therefore be developed to achieve better neurodevelopmental outcomes in these patients.
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Affiliation(s)
- Jun Kido
- Department of Pediatrics, Graduate School of Medical Sciences, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Shirou Matsumoto
- Department of Pediatrics, Graduate School of Medical Sciences, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Johannes Häberle
- University Children's Hospital Zurich and Children's Research Centre, Zurich, Switzerland
| | - Yoko Nakajima
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yoichi Wada
- Department of Pediatrics, Tohoku University School of Medicine, Sendai, Japan
| | - Narutaka Mochizuki
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Kei Murayama
- Department of Metabolism, Center for Medical Genetics, Chiba Children's Hospital, Chiba, Japan
| | - Tomoko Lee
- Department of Pediatrics, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroshi Mochizuki
- Division of Endocrinology and Metabolism, Saitama Children's Medical Center, Saitama, Japan
| | - Yoriko Watanabe
- Research Institute of Medical Mass Spectrometry, Kurume University School of Medicine, Kurume, Japan
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan
| | - Reiko Horikawa
- Division of Endocrinology and Metabolism, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kimitoshi Nakamura
- Department of Pediatrics, Graduate School of Medical Sciences, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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Hyperammonemic encephalopathy during XELOX regimen. Is it capecitabine or oxaliplatin responsible? Anticancer Drugs 2020; 31:1103-1105. [PMID: 32826413 DOI: 10.1097/cad.0000000000000987] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hyperammonemic encephalopathy represents a rare adverse effect of several chemotherapeutic agents, occurring in about 0.7% of patients treated with fluoropyrimidines, and it is independent from dihydropyrimidine dehydrogenase deficiency. Instead, its physiopathology is linked to the inhibition of Krebs cycle by fluoroacetate, leading to decreased ATP production, and to the inhibition of the urea cycle. Oxaliplatin seems to induce hyperammonemic encephalopathy in a similar way, acting on mitochondria. Here, we report the intriguing case of acute hyperammonemic encephalopathy in a 65-year-old patient with preserved liver function, who was treated with oxaliplatin and capecitabine for a metastatic, G1, atypical lung carcinoid. We reviewed the literature and found very few reports of oxaliplatin or capecitabine-induced hyperammonemic encephalopathy. Out of five cases of capecitabine-related hyperammonemic encephalopathy analyzed (four plus our case), median time to hyperammonemic encephalopathy onset was 6 days, with median serum ammonia levels of 213 μmol/L. Oxaliplatin-related hyperammonemic encephalopathy analyzed cases were three (two plus ours), with a median time to hyperammonemic encephalopathy of 11 days and median serum ammonia levels of 167 μmol/L. Identified predisposing factors for chemotherapy-induced hyperammonemia, such as dehydration, liver and renal impairment, infections, and sarcopenia were absent in our case. We hypothesize that the combination of a platinum-derivative and a fluoropyrimidine multiplies the risk of hyperammonemic encephalopathy, even in the absence of predisposing factors nor impaired liver function. We therefore suggest to always consider the risk of hyperammonemia when starting fluoropyrimidines-based chemotherapy, especially combined with platinum-derivatives, and to timely investigate neurologic symptoms monitoring ammonia serum levels.
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Posset R, Garbade SF, Gleich F, Gropman AL, de Lonlay P, Hoffmann GF, Garcia-Cazorla A, Nagamani SCS, Baumgartner MR, Schulze A, Dobbelaere D, Yudkoff M, Kölker S, Zielonka M. Long-term effects of medical management on growth and weight in individuals with urea cycle disorders. Sci Rep 2020; 10:11948. [PMID: 32686765 PMCID: PMC7371674 DOI: 10.1038/s41598-020-67496-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 06/08/2020] [Indexed: 12/18/2022] Open
Abstract
Low protein diet and sodium or glycerol phenylbutyrate, two pillars of recommended long-term therapy of individuals with urea cycle disorders (UCDs), involve the risk of iatrogenic growth failure. Limited evidence-based studies hamper our knowledge on the long-term effects of the proposed medical management in individuals with UCDs. We studied the impact of medical management on growth and weight development in 307 individuals longitudinally followed by the Urea Cycle Disorders Consortium (UCDC) and the European registry and network for Intoxication type Metabolic Diseases (E-IMD). Intrauterine growth of all investigated UCDs and postnatal linear growth of asymptomatic individuals remained unaffected. Symptomatic individuals were at risk of progressive growth retardation independent from the underlying disease and the degree of natural protein restriction. Growth impairment was determined by disease severity and associated with reduced or borderline plasma branched-chain amino acid (BCAA) concentrations. Liver transplantation appeared to have a beneficial effect on growth. Weight development remained unaffected both in asymptomatic and symptomatic individuals. Progressive growth impairment depends on disease severity and plasma BCAA concentrations, but cannot be predicted by the amount of natural protein intake alone. Future clinical trials are necessary to evaluate whether supplementation with BCAAs might improve growth in UCDs.
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Affiliation(s)
- Roland Posset
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Sven F Garbade
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Florian Gleich
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | | | - Pascale de Lonlay
- Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Service de Maladies Metaboliques (MaMEA), filière G2M, Université Paris-Descartes, Paris, France
| | - Georg F Hoffmann
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Angeles Garcia-Cazorla
- Hospital San Joan de Deu, Institut Pediàtric de Recerca. Servicio de Neurologia and CIBERER, ISCIII, Barcelona, Spain
| | - Sandesh C S Nagamani
- Department of Molecular and Human Genetics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Matthias R Baumgartner
- University Children's Hospital Zurich and Children's Research Center, Zurich, Switzerland
| | - Andreas Schulze
- University of Toronto and the Hospital for Sick Children, Toronto, ON, Canada
| | - Dries Dobbelaere
- Centre de Référence Maladies Héréditaires du Métabolisme de L'Enfant Et de L'Adulte, Jeanne de Flandre Hospital, CHRU Lille, and Faculty of Medicine, University Lille 2, Lille, France
| | - Marc Yudkoff
- School of Medicine and Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Stefan Kölker
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Matthias Zielonka
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany.
- Heidelberg Research Center for Molecular Medicine (HRCMM), Heidelberg, Germany.
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21
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Pontoizeau C, Roda C, Arnoux JB, Vignolo-Diard P, Brassier A, Habarou F, Barbier V, Grisel C, Abi-Warde MT, Boddaert N, Kuster A, Servais A, Kaminska A, Hennequin C, Dupic L, Lesage F, Touati G, Valayannopoulos V, Chadefaux-Vekemans B, Oualha M, Eisermann M, Ottolenghi C, de Lonlay P. Neonatal factors related to survival and intellectual and developmental outcome of patients with early-onset urea cycle disorders. Mol Genet Metab 2020; 130:110-117. [PMID: 32273051 DOI: 10.1016/j.ymgme.2020.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 03/14/2020] [Accepted: 03/14/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE We aimed to identify prognostic factors for survival and long-term intellectual and developmental outcome in neonatal patients with early-onset urea cycle disorders (UCD) experiencing hyperammonaemic coma. METHODS We retrospectively analysed ammonia (NH3) and glutamine levels, electroencephalogram and brain images obtained during neonatal coma of UCD patients born between 1995 and 2011 and managed at a single centre and correlated them to survival and intellectual and developmental outcome. RESULTS We included 38 neonates suffering from deficiencies of argininosuccinate synthetase (ASSD, N = 12), ornithine transcarbamylase (OTCD, N = 10), carbamoylphosphate synthetase 1 (CPSD, N = 7), argininosuccinate lyase (ASLD, N = 7), N-acetylglutamate synthase (NAGS, N = 1) or arginase (ARGD, N = 1). Symptoms occurred earlier in mitochondrial than in cytosolic UCD. Sixty-eight percent of patients survived, with a mean (standard deviation-SD) follow-up of 10.4 (5.3) years. Mortality was mostly observed in OTCD (N = 7/10) and CPSD (N = 4/7) patients. Plasma NH3 level during the neonatal period, expressed as area under the curve, but not glutamine level was associated with mortality (p = .044 and p = .610). 62.1% of the patients had normal intellectual and developmental outcome. Intellectual and developmental outcome tended to correlate with UCD subtype (p = .052). No difference in plasma NH3 or glutamine level during the neonatal period among developmental outcomes was identified. EEG severity was linked to UCD subtypes (p = .004), ammonia levels (p = .037), duration of coma (p = .043), and mortality during the neonatal period (p = .020). Status epilepticus was recorded in 6 patients, 3 of whom died neonatally, 1 developed a severe intellectual disability while the 2 last patients had a normal development. CONCLUSION UCD subtypes differed by survival rate, intellectual and developmental outcome and EEG features in the neonatal period. Hyperammonaemia expressed as area under the curve was associated with survival but not with intellectual and developmental outcome whereas glutamine was not associated with one of these outcomes. Prognostic value of video-EEG monitoring and the association between status epilepticus and mortality should be assessed in neonatal hyperammonaemic coma in further studies.
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Affiliation(s)
- Clément Pontoizeau
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France; Metabolomics Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France.
| | - Célina Roda
- Université de Paris, CRESS, INSERM, INRA, HERA team (Health Environmental Risk Assessment), F-75004 Paris, France
| | - Jean-Baptiste Arnoux
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | | | - Anais Brassier
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Florence Habarou
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France; Metabolomics Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Valérie Barbier
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Coraline Grisel
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Marie-Thérèse Abi-Warde
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Nathalie Boddaert
- Department of Pediatric Radiology, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, PRES Sorbonne Paris Cité, INSERM U1000, Institut Imagine, Paris, France
| | - Alice Kuster
- Pediatric Critical Care Unit, Femme-Enfants-Adolescents Hospital, Nantes University, Nantes, France
| | - Aude Servais
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France; Department of Nephrology, Transplantation, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Anna Kaminska
- Neurophysiology Unit, AP-HP, Necker Enfants Malades Hospital, Paris, France
| | - Carole Hennequin
- Biochemistry, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Laurent Dupic
- Pediatric Critical Care Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Fabrice Lesage
- Pediatric Critical Care Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Guy Touati
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Vassili Valayannopoulos
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Bernadette Chadefaux-Vekemans
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France; Metabolomics Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Mehdi Oualha
- Pediatric Critical Care Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Monika Eisermann
- Neurophysiology Unit, AP-HP, Necker Enfants Malades Hospital, Paris, France
| | - Chris Ottolenghi
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France; Metabolomics Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Pascale de Lonlay
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
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22
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Fan L, Zhao J, Jiang L, Xie L, Ma J, Li X, Cheng M. Molecular, biochemical, and clinical analyses of five patients with carbamoyl phosphate synthetase 1 deficiency. J Clin Lab Anal 2019; 34:e23124. [PMID: 31749211 PMCID: PMC7171324 DOI: 10.1002/jcla.23124] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 10/29/2019] [Accepted: 11/04/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Carbamoyl phosphate synthetase 1 deficiency (CPS1D) is a rare urea cycle disorder. The aim of this study was to present the clinical findings, management, biochemical data, molecular genetic analysis, and short-term prognosis of five children with CPS1D. METHODS The information of five CPS1D patients was retrospectively studied. We used targeted next-generation sequencing to identify carbamoyl phosphate synthetase 1 (CPS1) variants in patients suspected to have CPS1D. Candidate mutations were validated by Sanger sequencing. In silico and structure analyses were processed for the pathogenicity predictions of the identified mutations. RESULTS The patients had typically clinical manifestations and biochemical data of CPS1D. Genetic analysis revealed nine mutations in the CPS1 gene, including recurrence of c.1145C > T, five of which were firstly reported. Seven mutations were missense changes, while the remaining two were predicted to create premature stop codons. In silico and structure analyses showed that these genetic lesions were predicted to affect the function or stability of the enzyme. CONCLUSION We reported five cases of CPS1D. Five novel mutations of CPS1 gene were found. Mutations of CPS1 have private nature, and most of them are missense compound heterozygous. The mutation affecting residue predicted to interfere the catalytic sites, the internal tunnel, or the regulatory domain results in severe phenotype.
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Affiliation(s)
- Lijuan Fan
- Department of NeurologyChildren's Hospital of Chongqing Medical UniversityChongqingChina
- Ministry of Education Key Laboratory of Child Development and DisordersChongqingChina
- China International Science and Technology Cooperation Base of Child Development and Critical DisordersChongqingChina
- Chongqing Key Laboratory of PediatricsChongqingChina
| | - Jing Zhao
- Ministry of Education Key Laboratory of Child Development and DisordersChongqingChina
- China International Science and Technology Cooperation Base of Child Development and Critical DisordersChongqingChina
- Chongqing Key Laboratory of PediatricsChongqingChina
| | - Li Jiang
- Department of NeurologyChildren's Hospital of Chongqing Medical UniversityChongqingChina
- Ministry of Education Key Laboratory of Child Development and DisordersChongqingChina
- China International Science and Technology Cooperation Base of Child Development and Critical DisordersChongqingChina
- Chongqing Key Laboratory of PediatricsChongqingChina
| | - Lingling Xie
- Department of NeurologyChildren's Hospital of Chongqing Medical UniversityChongqingChina
- Ministry of Education Key Laboratory of Child Development and DisordersChongqingChina
- China International Science and Technology Cooperation Base of Child Development and Critical DisordersChongqingChina
- Chongqing Key Laboratory of PediatricsChongqingChina
| | - Jiannan Ma
- Department of NeurologyChildren's Hospital of Chongqing Medical UniversityChongqingChina
- Ministry of Education Key Laboratory of Child Development and DisordersChongqingChina
- China International Science and Technology Cooperation Base of Child Development and Critical DisordersChongqingChina
- Chongqing Key Laboratory of PediatricsChongqingChina
| | - Xiujuan Li
- Department of NeurologyChildren's Hospital of Chongqing Medical UniversityChongqingChina
- Ministry of Education Key Laboratory of Child Development and DisordersChongqingChina
- China International Science and Technology Cooperation Base of Child Development and Critical DisordersChongqingChina
- Chongqing Key Laboratory of PediatricsChongqingChina
| | - Min Cheng
- Department of NeurologyChildren's Hospital of Chongqing Medical UniversityChongqingChina
- Ministry of Education Key Laboratory of Child Development and DisordersChongqingChina
- China International Science and Technology Cooperation Base of Child Development and Critical DisordersChongqingChina
- Chongqing Key Laboratory of PediatricsChongqingChina
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23
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Ranucci G, Rigoldi M, Cotugno G, Bernabei SM, Liguori A, Gasperini S, Goffredo BM, Martinelli D, Monti L, Francalanci P, Candusso M, Parini R, Dionisi-Vici C. Chronic liver involvement in urea cycle disorders. J Inherit Metab Dis 2019; 42:1118-1127. [PMID: 31260111 DOI: 10.1002/jimd.12144] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 06/21/2019] [Accepted: 06/28/2019] [Indexed: 12/15/2022]
Abstract
The increased survival of urea cycle disorders (UCDs) patients has led the attention to clinical manifestations that characterize the long-term disease course. Acute and chronic liver disease have been anecdotally reported since the very first description of UCDs. However, a detailed analysis of long-term liver involvement in large patient cohorts is still needed. Chronic liver damage in UCDs has probably a multifactorial origin, but the specific underlying mechanisms of liver disease have not yet been well elucidated. In this study, we report on chronic liver involvement and on associated metabolic abnormalities in a large cohort of 102 UCD patients, followed by two reference centers in Italy. Chronic liver involvement was observed in over 60% of UCDs patients, and comparison between individual diseases showed a significant higher frequency in argininosuccinate lyase deficiency (ASLD) and in hyperornithinemia-hyperammonemia-homocitrullinemia (HHH) syndrome with elevation of transaminases and of gamma-GT in ASLD, and of alpha-fetoprotein in HHH syndrome. Also, consistent with a chronic hepatic dysfunction, ultrasound examination revealed more pronounced abnormalities in ASLD and in HHH syndrome, when compared to other UCDs. Our study highlights in a large UCDs patients' cohort that chronic liver disease is a common finding in UCDs, often with a distinct phenotype between different diseases. Furthers studies are needed to elucidate the specific involvement of different metabolic pathways in the pathogenesis of liver dysfunction in UCDs.
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Affiliation(s)
- Giusy Ranucci
- Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Miriam Rigoldi
- Medical Genetics Unit, Rare Diseases Center, ASST San Gerardo Hospital, Monza, Italy
| | - Giovanna Cotugno
- Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Silvia Maria Bernabei
- Division of Artificial Nutrition, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alessandra Liguori
- Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Serena Gasperini
- Pediatric Rare Diseases Unit, Department of Pediatrics, MBBM Foundation, ATS Monza e Brianza, Monza, Italy
| | | | - Diego Martinelli
- Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Lidia Monti
- Department of Radiology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paola Francalanci
- Department of Pathology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Manila Candusso
- Division of Hepatology and Gastroenterology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Rossella Parini
- Pediatric Rare Diseases Unit, Department of Pediatrics, MBBM Foundation, ATS Monza e Brianza, Monza, Italy
| | - Carlo Dionisi-Vici
- Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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24
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Diez-Fernandez C, Hertig D, Loup M, Diserens G, Henry H, Vermathen P, Nuoffer JM, Häberle J, Braissant O. Argininosuccinate neurotoxicity and prevention by creatine in argininosuccinate lyase deficiency: An in vitro study in rat three-dimensional organotypic brain cell cultures. J Inherit Metab Dis 2019; 42:1077-1087. [PMID: 30907007 DOI: 10.1002/jimd.12090] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 03/04/2019] [Accepted: 03/22/2019] [Indexed: 12/31/2022]
Abstract
The urea cycle disorder (UCD) argininosuccinate lyase (ASL) deficiency, caused by a defective ASL enzyme, exhibits a wide range of phenotypes, from life-threatening neonatal hyperammonemia to asymptomatic patients, with only the biochemical marker argininosuccinic acid (ASA) elevated in body fluids. Remarkably, even without ever suffering from hyperammonemia, patients often develop severe cognitive impairment and seizures. The goal of this study was to understand the effect on the known toxic metabolite ASA and the assumed toxic metabolite guanidinosuccinic acid (GSA) on developing brain cells, and to evaluate the potential role of creatine (Cr) supplementation, as it was described protective for brain cells exposed to ammonia. We used an in vitro model, in which we exposed three-dimensional (3D) organotypic rat brain cell cultures in aggregates to different combinations of the metabolites of interest at two time points (representing two different developmental stages). After harvest and cryopreservation of the cell cultures, the samples were analyzed mainly by metabolite analysis, immunohistochemistry, and western blotting. ASA and GSA were found toxic for astrocytes and neurons. This toxicity could be reverted in vitro by Cr. As well, an antiapoptotic effect of ASA was revealed, which could contribute to the neurotoxicity in ASL deficiency. Further studies in human ASL deficiency will be required to understand the biochemical situation in the brain of affected patients, and to investigate the impact of high or low arginine doses on brain Cr availability. In addition, clinical trials to evaluate the beneficial effect of Cr supplementation in ASL deficiency would be valuable.
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Affiliation(s)
- Carmen Diez-Fernandez
- Division of Metabolism and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Damian Hertig
- Division of Pediatric Endocrinology, Diabetology and Metabolism and University Institute of Clinical Chemistry, Inselspital, University Hospital, University of Bern, Bern, Switzerland
- AMSM, Department of Biomedical Research, University of Bern, Bern, Switzerland
- AMSM, Department of Radiology, University of Bern, Bern, Switzerland
- Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland
| | - Marc Loup
- Service of Clinical Chemistry, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Gaelle Diserens
- AMSM, Department of Biomedical Research, University of Bern, Bern, Switzerland
- AMSM, Department of Radiology, University of Bern, Bern, Switzerland
| | - Hugues Henry
- Service of Clinical Chemistry, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Peter Vermathen
- AMSM, Department of Biomedical Research, University of Bern, Bern, Switzerland
- AMSM, Department of Radiology, University of Bern, Bern, Switzerland
| | - Jean-Marc Nuoffer
- Division of Pediatric Endocrinology, Diabetology and Metabolism and University Institute of Clinical Chemistry, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | - Johannes Häberle
- Division of Metabolism and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Olivier Braissant
- Service of Clinical Chemistry, Lausanne University Hospital and University of Lausanne, Switzerland
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25
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Waisbren SE, Stefanatos AK, Kok TMY, Ozturk‐Hismi B. Neuropsychological attributes of urea cycle disorders: A systematic review of the literature. J Inherit Metab Dis 2019; 42:1176-1191. [PMID: 31268178 PMCID: PMC7250134 DOI: 10.1002/jimd.12146] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 06/25/2019] [Accepted: 07/01/2019] [Indexed: 12/30/2022]
Abstract
Urea cycle disorders (UCDs) are rare inherited metabolic conditions that impair the effectiveness of the urea cycle responsible for removing excess ammonia from the body. The estimated incidence of UCDs is 1:35 000 births, or approximately 113 new patients with UCD per year. This review summarizes neuropsychological outcomes among patients with the eight UCDs in reports published since 1980. Rates of intellectual disabilities published before (and including) 2000 and after 2000 were pooled and compared for each UCD. Since diagnoses for UCDs tended to occur earlier and better treatments became more readily available after the turn of the century, this assessment will characterize the extent that current management strategies have improved neuropsychological outcomes. The pooled sample included data on cognitive abilities of 1649 individuals reported in 58 citations. A total of 556 patients (34%) functioned in the range of intellectual disabilities. The decline in the proportion of intellectual disabilities in six disorders, ranged from 7% to 41%. Results from various studies differed and the cohorts varied with respect to age at symptom onset, age at diagnosis and treatment initiation, current age, severity of the metabolic deficiency, management strategies, and ethnic origins. The proportion of cases with intellectual disabilities ranged from 9% to 65% after 2000 in the seven UCDs associated with cognitive deficits. Positive outcomes from some studies suggest that it is possible to prevent or reverse the adverse impact of UCDs on neuropsychological functioning. It is time to "raise the bar" in terms of expectations for treatment effectiveness.
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Affiliation(s)
- Susan E. Waisbren
- Division of Genetics and Genomics, Department of Pediatrics, Boston Children's HospitalBostonMassachusetts
- Department of Medicine, Harvard Medical SchoolBostonMassachusetts
| | - Arianna K. Stefanatos
- Department of Child & Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of PhiladelphiaPhiladelphiaPennsylvania
| | | | - Burcu Ozturk‐Hismi
- Division of Genetics and Genomics, Department of Pediatrics, Boston Children's HospitalBostonMassachusetts
- Tepecik Education and Research HospitalIzmirTurkey
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26
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Baruteau J, Diez-Fernandez C, Lerner S, Ranucci G, Gissen P, Dionisi-Vici C, Nagamani S, Erez A, Häberle J. Argininosuccinic aciduria: Recent pathophysiological insights and therapeutic prospects. J Inherit Metab Dis 2019; 42:1147-1161. [PMID: 30723942 DOI: 10.1002/jimd.12047] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 12/20/2018] [Indexed: 12/30/2022]
Abstract
The first patients affected by argininosuccinic aciduria (ASA) were reported 60 years ago. The clinical presentation was initially described as similar to other urea cycle defects, but increasing evidence has shown overtime an atypical systemic phenotype with a paradoxical observation, that is, a higher rate of neurological complications contrasting with a lower rate of hyperammonaemic episodes. The disappointing long-term clinical outcomes of many of the patients have challenged the current standard of care and therapeutic strategy, which aims to normalize plasma ammonia and arginine levels. Interrogations have raised about the benefit of newborn screening or liver transplantation on the neurological phenotype. Over the last decade, novel discoveries enabled by the generation of new transgenic argininosuccinate lyase (ASL)-deficient mouse models have been achieved, such as, a better understanding of ASL and its close interaction with nitric oxide metabolism, ASL physiological role outside the liver, and the pathophysiological role of oxidative/nitrosative stress or excessive arginine treatment. Here, we present a collaborative review, which highlights these recent discoveries and novel emerging concepts about ASL role in human physiology, ASA clinical phenotype and geographic prevalence, limits of current standard of care and newborn screening, pathophysiology of the disease, and emerging novel therapies. We propose recommendations for monitoring of ASA patients. Ongoing research aims to better understand the underlying pathogenic mechanisms of the systemic disease to design novel therapies.
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Affiliation(s)
- Julien Baruteau
- UCL Great Ormond Street Institute of Child Health, NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
- Metabolic Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Carmen Diez-Fernandez
- Division of Metabolism and Children Research Centre (CRC), University Children's Hospital, Zurich, Switzerland
| | - Shaul Lerner
- Department of Biological Regulation, Weizmann Institute of Science, Rehovot, Israël
| | - Giusy Ranucci
- Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paul Gissen
- UCL Great Ormond Street Institute of Child Health, NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
- Metabolic Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Carlo Dionisi-Vici
- Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Sandesh Nagamani
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
| | - Ayelet Erez
- Department of Biological Regulation, Weizmann Institute of Science, Rehovot, Israël
| | - Johannes Häberle
- Division of Metabolism and Children Research Centre (CRC), University Children's Hospital, Zurich, Switzerland
- Zurich Center for Integrative Human Physiology (ZIHP) and Neuroscience Center Zurich (ZNZ), Zurich, Switzerland
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27
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Häberle J, Burlina A, Chakrapani A, Dixon M, Karall D, Lindner M, Mandel H, Martinelli D, Pintos-Morell G, Santer R, Skouma A, Servais A, Tal G, Rubio V, Huemer M, Dionisi-Vici C. Suggested guidelines for the diagnosis and management of urea cycle disorders: First revision. J Inherit Metab Dis 2019; 42:1192-1230. [PMID: 30982989 DOI: 10.1002/jimd.12100] [Citation(s) in RCA: 292] [Impact Index Per Article: 48.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 04/04/2019] [Accepted: 04/08/2019] [Indexed: 02/06/2023]
Abstract
In 2012, we published guidelines summarizing and evaluating late 2011 evidence for diagnosis and therapy of urea cycle disorders (UCDs). With 1:35 000 estimated incidence, UCDs cause hyperammonemia of neonatal (~50%) or late onset that can lead to intellectual disability or death, even while effective therapies do exist. In the 7 years that have elapsed since the first guideline was published, abundant novel information has accumulated, experience on newborn screening for some UCDs has widened, a novel hyperammonemia-causing genetic disorder has been reported, glycerol phenylbutyrate has been introduced as a treatment, and novel promising therapeutic avenues (including gene therapy) have been opened. Several factors including the impact of the first edition of these guidelines (frequently read and quoted) may have increased awareness among health professionals and patient families. However, under-recognition and delayed diagnosis of UCDs still appear widespread. It was therefore necessary to revise the original guidelines to ensure an up-to-date frame of reference for professionals and patients as well as for awareness campaigns. This was accomplished by keeping the original spirit of providing a trans-European consensus based on robust evidence (scored with GRADE methodology), involving professionals on UCDs from nine countries in preparing this consensus. We believe this revised guideline, which has been reviewed by several societies that are involved in the management of UCDs, will have a positive impact on the outcomes of patients by establishing common standards, and spreading and harmonizing good practices. It may also promote the identification of knowledge voids to be filled by future research.
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Affiliation(s)
- Johannes Häberle
- University Children's Hospital Zurich and Children's Research Centre, Zurich, Switzerland
| | - Alberto Burlina
- Division of Inborn Metabolic Disease, Department of Pediatrics, University Hospital Padua, Padova, Italy
| | - Anupam Chakrapani
- Department of Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Marjorie Dixon
- Dietetics, Great Ormond Street Hospital for Children, NHS Trust, London, UK
| | - Daniela Karall
- Clinic for Pediatrics, Division of Inherited Metabolic Disorders, Medical University of Innsbruck, Innsbruck, Austria
| | - Martin Lindner
- University Children's Hospital, Frankfurt am Main, Germany
| | - Hanna Mandel
- Institute of Human Genetics and metabolic disorders, Western Galilee Medical Center, Nahariya, Israel
| | - Diego Martinelli
- Division of Metabolism, Bambino Gesù Children's Hospital, Rome, Italy
| | - Guillem Pintos-Morell
- Centre for Rare Diseases, University Hospital Vall d'Hebron, Barcelona, Spain
- CIBERER_GCV08, Research Institute IGTP, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - René Santer
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anastasia Skouma
- Institute of Child Health, Agia Sofia Children's Hospital, Athens, Greece
| | - Aude Servais
- Service de Néphrologie et maladies métaboliques adulte Hôpital Necker 149, Paris, France
| | - Galit Tal
- The Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Vicente Rubio
- Instituto de Biomedicina de Valencia (IBV-CSIC), Centro de Investigación Biomédica en Red para Enfermedades Raras (CIBERER), Valencia, Spain
| | - Martina Huemer
- University Children's Hospital Zurich and Children's Research Centre, Zurich, Switzerland
- Department of Paediatrics, Landeskrankenhaus Bregenz, Bregenz, Austria
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Stepien KM, Geberhiwot T, Hendriksz CJ, Treacy EP. Challenges in diagnosing and managing adult patients with urea cycle disorders. J Inherit Metab Dis 2019; 42:1136-1146. [PMID: 30932189 DOI: 10.1002/jimd.12096] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 03/28/2019] [Indexed: 12/15/2022]
Abstract
Urea cycle disorders (UCD) are a group of rare inherited metabolic conditions of amino acid catabolism caused by an enzyme deficiency within the hepatic ammonia detoxification pathway. The presentation of these disorders ranges from life-threatening intoxication in the neonate to asymptomatic status in adults. Late-onset UCDs can present for the first time in adulthood and may mimic other causes of acute confusion or psychiatric diseases, and are often associated with neurological symptoms. Late-onset UCDs may become apparent during periods of metabolic stress such as rapid weight loss, gastric bypass surgery, chronic starvation or the postpartum period. Early diagnosis is critical for effective treatment and to prevent long-term complications of hyperammonemia. The challenges of management of adults include for example: (a) poor compliance to dietary and medical treatment which can result in recurrent hospital admissions; (b) severe neurological dysfunction; (c) the management of pregnancy and the postpartum period; and (d) access to multidisciplinary care peri-operatively. In this review, we highlight a number of challenges in the diagnosis and management of adult patient with late-onset UCDs and suggest a systematic management approach.
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Affiliation(s)
- Karolina M Stepien
- Mark Holland Metabolic Unit, Adult Inherited Metabolic Diseases Department, Salford Royal NHS Foundation Trust, Salford, UK
| | - Tarekegn Geberhiwot
- Centre for Endocrinology, Diabetes and Metabolism, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Christian J Hendriksz
- Department of Paediatrics, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
| | - Eileen P Treacy
- National Centre for Inherited Metabolic Diseases, The Mater Misericordiae University Hospital, Dublin, Ireland
- Department of Paediatrics, Trinity College, Dublin, Ireland
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Hasbaoui BE, Boujrad S, Abilkacem R, Agadr A. [Vomiting associated with weight stagnation and convulsions: urea cycle disorder should be suspected]. Pan Afr Med J 2019; 31:103. [PMID: 31037164 PMCID: PMC6462384 DOI: 10.11604/pamj.2018.31.103.11403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 08/02/2017] [Indexed: 11/11/2022] Open
Abstract
Dans certaines maladies métaboliques héréditaires, les vomissements peuvent apparaître comme un symptôme étant au premier plan, en particulier les anomalies du cycle de l'urée, qui sont habituellement diagnostiqués en période néonatale ou dans l'enfance. Nous en rapportons un cas de révélation tardive par un état de mal convulsif. Nous rapportons le cas d'une patiente âgée de 13 ans, qui a été hospitalisé pour prise en charge d'un état de mal convulsif et un retard staturo-pondéral. L'interrogatoire a révélé la notion de vomissements chroniques avec des troubles du comportement, ralentissement idéomoteur et céphalées. L'examen a trouvé une ataxie. La ponction lombaire et le scanner cérébral sont normaux. Une ammoniémie nettement augmentée est mise en évidence 75 micromoles/l (11-50). La chromatographie des acides aminés dans le sang a montré une augmentation de la glutamine et de l'alanine, La chromatographie des acides aminés dans les urines a montré une augmentation des acides aminés basiques évoquant un déficit du cycle de l'urée par déficit de l'enzyme Argininosuccinate lyase. La patiente a été traité en urgence par une alimentation exclusivement glucidolipidique, et par benzoate de sodium permettant une amélioration de l'état clinique, et une reprise de poids. Les crises convulsives ont été maîtrisées par le phénobarbital. L'enquête familiale a trouvé une sœur âgée de 20 ans suivie depuis l'âge de 3 ans pour crises convulsives traité par le phénobarbital dont le bilan métabolique réalisé dans notre service a objectivé la même anomalie du cycle de l'urée que sa sœur. A tout âge, devant une encéphalopathie avec épilepsie, vomissement, stagnation pondérale et hyperammoniémie, il faut penser à un déficit du cycle de l'urée. Le diagnostic est très souvent posé lors d'un accès neuro-digestif aigue associant vomissements, troubles de conscience et/ou crises convulsives.
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Affiliation(s)
- Brahim El Hasbaoui
- Service de Pédiatrie, Hôpital Militaire d'Instruction Mohammed V, Faculté de Médecine et de Pharmacie, Université Mohammed V, Rabat, Maroc
| | - Saloua Boujrad
- Service de Pédiatrie, Hôpital Militaire d'Instruction Mohammed V, Faculté de Médecine et de Pharmacie, Université Mohammed V, Rabat, Maroc
| | - Rachid Abilkacem
- Service de Pédiatrie, Hôpital Militaire d'Instruction Mohammed V, Faculté de Médecine et de Pharmacie, Université Mohammed V, Rabat, Maroc
| | - Aomar Agadr
- Service de Pédiatrie, Hôpital Militaire d'Instruction Mohammed V, Faculté de Médecine et de Pharmacie, Université Mohammed V, Rabat, Maroc
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5-Fluorouracil rechallenge after 5-fluorouracil-induced hyperammonemic encephalopathy. Anticancer Drugs 2019; 30:313-317. [DOI: 10.1097/cad.0000000000000730] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Buerger C, Garbade SF, Alber FD, Waisbren SE, McCarter R, Kölker S, Burgard P. Impairment of cognitive function in ornithine transcarbamylase deficiency is global rather than domain-specific and is associated with disease onset, sex, maximum ammonium, and number of hyperammonemic events. J Inherit Metab Dis 2019; 42:243-253. [PMID: 30671983 PMCID: PMC7439789 DOI: 10.1002/jimd.12013] [Citation(s) in RCA: 14] [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: 06/22/2018] [Revised: 10/18/2018] [Accepted: 11/12/2018] [Indexed: 12/15/2022]
Abstract
Beginning in 2006, the Urea Cycle Disorders Consortium (UCDC) has conducted a longitudinal study of eight inherited deficiencies of enzymes and transporters of the urea cycle, including 444 individuals with ornithine transcarbamylase deficiency (OTCD), of whom 300 (67 males, 233 females) received psychological evaluation. In a cross-sectional study (age range, 3-71 years), analysis of covariance (ANCOVA) determined the association between outcomes in five cognitive domains (global intelligence, executive functions, memory, visuomotor integration, visual perception) and sex, age at testing and timing of disease onset defined as early onset (≤28 days; EO), late onset (LO), or asymptomatic (AS). The dataset of 183 subjects with complete datasets (31 males, 152 females) revealed underrepresentation of EO subjects (2 males, 4 females), who were excluded from the ANCOVA. Although mean scores of LO and AS individuals were within 1 SD of the population norm, AS subjects attained significantly higher scores than LO subjects and males higher scores than females. Correlations between cognitive domains were high, particularly intelligence proved to be a distinguished indicator for cognitive functioning. Maximum plasma ammonium concentration and intelligence correlated significantly higher in EO (r = -0.47) than in LO subjects (r = 0.04). Correlation between the number of hyperammonemic events and intelligence scores were similar for EO (r = -0.30) and LO (r = -0.26) individuals. The number of clinical symptoms was significantly associated with intelligence (r = -0.28) but not with scores in other domains. Results suggest that OTCD has a global impact on cognitive functioning rather than a specific effect on distinct cognitive domains.
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Affiliation(s)
- Corinna Buerger
- Division of Neuropaediatrics and Inherited Metabolic Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Sven F. Garbade
- Division of Neuropaediatrics and Inherited Metabolic Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Fabienne Dietrich Alber
- Division of Metabolism and Children’s Research Centre, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Susan E. Waisbren
- Division of Genetics and Genomics, Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Robert McCarter
- Center for Translational Sciences, Children’s National Health System, The George Washington University, Washington, District of Columbia
| | - Stefan Kölker
- Division of Neuropaediatrics and Inherited Metabolic Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter Burgard
- Division of Neuropaediatrics and Inherited Metabolic Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
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Abstract
Inborn errors of metabolism comprise a wide array of diseases and complications in the pediatric patient. The rarity of these disorders limits the ability to conduct and review robust literature regarding the disease states, mechanisms of dysfunction, treatments, and outcomes. Often, treatment plans will be based on the pathophysiology associated with the disorder and theoretical agents that may be involved in the metabolic process. Medication therapies usually consist of natural or herbal products. Established efficacious pediatric doses for these products are difficult to find in tertiary resources, and adverse effects are routinely limited to single case reports. This review article attempts to summarize some of the more common inborn errors of metabolism in a manner that is applicable to pharmacists who will provide care for these patients.
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Chongsrisawat V, Damrongphol P, Ittiwut C, Ittiwut R, Suphapeetiporn K, Shotelersuk V. The phenotypic and mutational spectrum of Thai female patients with ornithine transcarbamylase deficiency. Gene 2018; 679:377-381. [PMID: 30223008 DOI: 10.1016/j.gene.2018.09.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 08/26/2018] [Accepted: 09/13/2018] [Indexed: 10/28/2022]
Abstract
Ornithine transcarbamylase deficiency (OTCD) is an X-linked urea cycle disorder affecting both males and females. Hemizygous males commonly present with severe hyperammonemic encephalopathy during the neonatal period. Heterozygous females have great phenotypic variability. The majority of female patients can manifest later in life or have unrecognized symptoms, making the diagnosis of OTCD in females very challenging. Here we report on three unrelated Thai female cases with OTCD presenting with different manifestations including aggressive behavior, acute liver failure and severe encephalopathy. Whole exome sequencing successfully identified disease-causing mutations in all three cases including two novel ones: the c.209_210delAA (p.Lys70Argfs*17) and the c.850T>A (p.Tyr284Asn). This study affirms variable symptoms in female patients with OTCD and emphasizes the importance of early recognition and prompt management for favorable outcomes. In addition, identification of two novel causative variants expands the genotypic spectrum of OTC.
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Affiliation(s)
- Voranush Chongsrisawat
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Ponghatai Damrongphol
- Center of Excellence for Medical Genomics, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand; Excellence Center for Medical Genetics, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok 10330, Thailand
| | - Chupong Ittiwut
- Center of Excellence for Medical Genomics, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand; Excellence Center for Medical Genetics, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok 10330, Thailand
| | - Rungnapa Ittiwut
- Center of Excellence for Medical Genomics, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand; Excellence Center for Medical Genetics, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok 10330, Thailand
| | - Kanya Suphapeetiporn
- Center of Excellence for Medical Genomics, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand; Excellence Center for Medical Genetics, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok 10330, Thailand.
| | - Vorasuk Shotelersuk
- Center of Excellence for Medical Genomics, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand; Excellence Center for Medical Genetics, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok 10330, Thailand
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Quaglia A, Roberts EA, Torbenson M. Developmental and Inherited Liver Disease. MACSWEEN'S PATHOLOGY OF THE LIVER 2018:111-274. [DOI: 10.1016/b978-0-7020-6697-9.00003-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2025]
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Longo N, Holt RJ. Glycerol phenylbutyrate for the maintenance treatment of patients with deficiencies in enzymes of the urea cycle. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1405807] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Nicola Longo
- Division of Medical Genetics, University of Utah, Salt Lake City, UT, USA
| | - Robert J. Holt
- Medical Affairs, Horizon Pharma, Lake Forest, IL, USA
- Department of Pharmacy Practice, University of Illinois, Chicago, IL, USA
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Berry SA, Longo N, Diaz GA, McCandless SE, Smith WE, Harding CO, Zori R, Ficicioglu C, Lichter-Konecki U, Robinson B, Vockley J. Safety and efficacy of glycerol phenylbutyrate for management of urea cycle disorders in patients aged 2months to 2years. Mol Genet Metab 2017; 122:46-53. [PMID: 28916119 DOI: 10.1016/j.ymgme.2017.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 09/01/2017] [Accepted: 09/01/2017] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Glycerol phenylbutyrate (GPB) is approved in the US for the management of patients 2months of age and older with urea cycle disorders (UCDs) that cannot be managed with protein restriction and/or amino acid supplementation alone. Limited data exist on the use of nitrogen conjugation agents in very young patients. METHODS Seventeen patients (15 previously on other nitrogen scavengers) with all types of UCDs aged 2months to 2years were switched to, or started, GPB. Retrospective data up to 12months pre-switch and prospective data during initiation of therapy were used as baseline measures. The primary efficacy endpoint of the integrated analysis was the successful transition to GPB with controlled ammonia (<100μmol/L and no clinical symptoms). Secondary endpoints included glutamine and levels of other amino acids. Safety endpoints included adverse events, hyperammonemic crises (HACs), and growth and development. RESULTS 82% and 53% of patients completed 3 and 6months of therapy, respectively (mean 8.85months, range 6days-18.4months). Patients transitioned to GPB maintained excellent control of ammonia and glutamine levels. There were 36 HACs in 11 patients before GPB and 11 in 7 patients while on GPB, with a reduction from 2.98 to 0.88 episodes per year. Adverse events occurring in at least 10% of patients while on GPB were neutropenia, vomiting, diarrhea, pyrexia, hypophagia, cough, nasal congestion, rhinorrhea, rash/papule. CONCLUSION GPB was safe and effective in UCD patients aged 2months to 2years. GPB use was associated with good short- and long-term control of ammonia and glutamine levels, and the annualized frequency of hyperammonemic crises was lower during the study than before the study. There was no evidence for any previously unknown toxicity of GPB.
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Affiliation(s)
| | | | - George A Diaz
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shawn E McCandless
- Center for Human Genetics, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | | | | | | | - Can Ficicioglu
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | | | - Jerry Vockley
- Children's Hospital of Pittsburgh, Pittsburgh, PA, USA; University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Bigot A, Tchan MC, Thoreau B, Blasco H, Maillot F. Liver involvement in urea cycle disorders: a review of the literature. J Inherit Metab Dis 2017; 40:757-769. [PMID: 28900784 DOI: 10.1007/s10545-017-0088-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 08/13/2017] [Accepted: 08/29/2017] [Indexed: 12/20/2022]
Abstract
Urea cycle disorders (UCDs) are inborn errors of metabolism of the nitrogen detoxification pathway and encompass six principal enzymatic deficiencies. The aging of UCD patients leads to a better knowledge of the long-term natural history of the condition and to the reporting of previously unnoticed manifestations. Despite historical evidence of liver involvement in UCDs, little attention has been paid to this organ until recently. Hence, we reviewed the available scientific evidence on acute and chronic liver dysfunction and liver carcinogenesis in UCDs and discuss their pathophysiology. Overall, liver involvement, such as acute liver failure or steatotic-like disease, which may evolve toward cirrhosis, has been reported in all six main UCDs. Excessive glycogen storage is also a prominent histologic feature, and hypoglycemia has been reported in citrin deficiency. Hepatocarcinomas seem frequent in some UCDs, such as in citrin deficiency, and can sometimes occur in non-cirrhotic patients. UCDs may differ in liver involvement according to the enzymatic deficiency. Ornithine transcarbamylase deficiency may be associated more with acute liver failure and argininosuccinic aciduria with chronic liver failure and cirrhosis. Direct toxicity of metabolites, downstream metabolic deficiencies, impaired tricarboxylic acid cycle, oxidative stress, mitochondrial dysfunction, energy deficit, and putative toxicity of therapies combine in various ways to cause the different liver diseases reported.
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Affiliation(s)
- Adrien Bigot
- CHRU de Tours, service médecine interne, Tours, France.
- CHRU de Tours, centre de référence des maladies héréditaires du métabolisme, Tours, France.
- Department of Genetic Medicine, Westmead Hospital, Sydney, Australia.
- Service de Médecine Interne, Hôpital Bretonneau, 2, boulevard Tonnelle, 37044, Tours, France.
| | - Michel C Tchan
- Department of Genetic Medicine, Westmead Hospital, Sydney, Australia
| | - Benjamin Thoreau
- CHRU de Tours, service médecine interne, Tours, France
- CHRU de Tours, centre de référence des maladies héréditaires du métabolisme, Tours, France
- Université François Rabelais, Tours, France
- UMR INSERM U 1069, Tours, France
| | - Hélène Blasco
- CHRU de Tours, centre de référence des maladies héréditaires du métabolisme, Tours, France
- Université François Rabelais, Tours, France
- CHRU de Tours, service de biochimie-biologie moléculaire, Tours, France
- UMR INSERM U930, 37000, Tours, France
| | - François Maillot
- CHRU de Tours, service médecine interne, Tours, France
- CHRU de Tours, centre de référence des maladies héréditaires du métabolisme, Tours, France
- Université François Rabelais, Tours, France
- UMR INSERM U 1069, Tours, France
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Nettesheim S, Kölker S, Karall D, Häberle J, Posset R, Hoffmann GF, Heinrich B, Gleich F, Garbade SF. Incidence, disease onset and short-term outcome in urea cycle disorders -cross-border surveillance in Germany, Austria and Switzerland. Orphanet J Rare Dis 2017; 12:111. [PMID: 28619060 PMCID: PMC5472961 DOI: 10.1186/s13023-017-0661-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 05/30/2017] [Indexed: 12/30/2022] Open
Abstract
Background Urea cycle disorders (UCDs) are a group of rare inherited metabolic disorders. Affected individuals often present with hyperammonemic encephalopathy (HE) and have an increased risk of severe neurologic disease and early death. The study aims to provide epidemiologic data and to describe the disease manifestation and short-term outcome. Method Cross-border surveillance of newly diagnosed patients with UCDs - below 16 years of age - was performed from July 2012 to June 2015 in Germany and Austria and from January 2012 to December 2015 in Switzerland. Inquiries were sent monthly to all Pediatric Departments in Germany and Switzerland, and quarterly to the Austrian Metabolic Group. In addition, data were collected via a second source (metabolic laboratories) in all three countries. Results Between July 2012 and June 2015, fifty patients (Germany: 39, Austria: 7, Switzerland: 4) with newly diagnosed UCDs were reported and later confirmed resulting in an estimated cumulative incidence of 1 in 51,946 live births. At diagnosis, thirty-nine patients were symptomatic and 11 asymptomatic [10 identified by newborn screening (NBS), 1 by high-risk-family screening (HRF)]. The majority of symptomatic patients (30 of 39 patients) developed HE with (n = 25) or without coma (n = 5), 28 of them with neonatal onset. Despite emergency treatment 15 of 30 patients with HE already died during the newborn period. Noteworthy, 10 of 11 patients diagnosed by NBS or HRF remained asymptomatic. Comparison with the European registry and network for intoxication type metabolic diseases (E-IMD) demonstrated that cross-national surveillance identified a higher number of clinically severe UCD patients characterized by earlier onset of symptoms, higher peak ammonium concentrations in plasma and higher mortality. Conclusion Cross-border surveillance is a powerful tool to identify patients with UCDs demonstrating that (1) the cumulative incidence of UCDs is lower than originally suggested, (2) the mortality rate is still high in patients with neonatal onset of symptoms, and (3) onset type and peak plasma ammonium concentration predict mortality.
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Affiliation(s)
- Susanne Nettesheim
- Division of Neuropediatrics and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Stefan Kölker
- Division of Neuropediatrics and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Daniela Karall
- Medical University of Innsbruck, Clinic for Pediatrics I, Inherited Metabolic Disorders, Innsbruck, Austria
| | - Johannes Häberle
- University Children's Hospital Zurich, Division of Metabolism and Children's Research Center, Zurich, Switzerland
| | - Roland Posset
- Division of Neuropediatrics and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Georg F Hoffmann
- Division of Neuropediatrics and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Beate Heinrich
- Erhebungseinheit für Seltene Pädiatrische Erkrankungen in Deutschland, Coordination Center for Clinical Studies, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Florian Gleich
- Division of Neuropediatrics and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Sven F Garbade
- Division of Neuropediatrics and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany.
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Baruteau J, Jameson E, Morris AA, Chakrapani A, Santra S, Vijay S, Kocadag H, Beesley CE, Grunewald S, Murphy E, Cleary M, Mundy H, Abulhoul L, Broomfield A, Lachmann R, Rahman Y, Robinson PH, MacPherson L, Foster K, Chong WK, Ridout DA, Bounford KM, Waddington SN, Mills PB, Gissen P, Davison JE. Expanding the phenotype in argininosuccinic aciduria: need for new therapies. J Inherit Metab Dis 2017; 40:357-368. [PMID: 28251416 PMCID: PMC5393288 DOI: 10.1007/s10545-017-0022-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/24/2017] [Accepted: 01/25/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVES This UK-wide study defines the natural history of argininosuccinic aciduria and compares long-term neurological outcomes in patients presenting clinically or treated prospectively from birth with ammonia-lowering drugs. METHODS Retrospective analysis of medical records prior to March 2013, then prospective analysis until December 2015. Blinded review of brain MRIs. ASL genotyping. RESULTS Fifty-six patients were defined as early-onset (n = 23) if symptomatic < 28 days of age, late-onset (n = 23) if symptomatic later, or selectively screened perinatally due to a familial proband (n = 10). The median follow-up was 12.4 years (range 0-53). Long-term outcomes in all groups showed a similar neurological phenotype including developmental delay (48/52), epilepsy (24/52), ataxia (9/52), myopathy-like symptoms (6/52) and abnormal neuroimaging (12/21). Neuroimaging findings included parenchymal infarcts (4/21), focal white matter hyperintensity (4/21), cortical or cerebral atrophy (4/21), nodular heterotopia (2/21) and reduced creatine levels in white matter (4/4). 4/21 adult patients went to mainstream school without the need of additional educational support and 1/21 lives independently. Early-onset patients had more severe involvement of visceral organs including liver, kidney and gut. All early-onset and half of late-onset patients presented with hyperammonaemia. Screened patients had normal ammonia at birth and received treatment preventing severe hyperammonaemia. ASL was sequenced (n = 19) and 20 mutations were found. Plasma argininosuccinate was higher in early-onset compared to late-onset patients. CONCLUSIONS Our study further defines the natural history of argininosuccinic aciduria and genotype-phenotype correlations. The neurological phenotype does not correlate with the severity of hyperammonaemia and plasma argininosuccinic acid levels. The disturbance in nitric oxide synthesis may be a contributor to the neurological disease. Clinical trials providing nitric oxide to the brain merit consideration.
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Affiliation(s)
- Julien Baruteau
- Gene Transfer Technology Group, Institute for Women’s Health, University College London, London, UK
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, WC1N 3JH London, UK
- Genetics and Genomic Medicine Programme, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Elisabeth Jameson
- Metabolic Medicine Department, Royal Manchester Children Hospital NHS Foundation Trust, Manchester, UK
| | - Andrew A. Morris
- Metabolic Medicine Department, Royal Manchester Children Hospital NHS Foundation Trust, Manchester, UK
| | - Anupam Chakrapani
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, WC1N 3JH London, UK
- Metabolic Medicine Department, Birmingham Children’s Hospital NHS Foundation Trust, Birmingham, UK
| | - Saikat Santra
- Metabolic Medicine Department, Birmingham Children’s Hospital NHS Foundation Trust, Birmingham, UK
| | - Suresh Vijay
- Metabolic Medicine Department, Birmingham Children’s Hospital NHS Foundation Trust, Birmingham, UK
| | - Huriye Kocadag
- Gene Transfer Technology Group, Institute for Women’s Health, University College London, London, UK
| | - Clare E. Beesley
- North East Thames Regional Genetic Services, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Stephanie Grunewald
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, WC1N 3JH London, UK
| | - Elaine Murphy
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Maureen Cleary
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, WC1N 3JH London, UK
| | - Helen Mundy
- Metabolic Medicine Department, Evelina Children’s Hospital, London, UK
| | - Lara Abulhoul
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, WC1N 3JH London, UK
| | - Alexander Broomfield
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, WC1N 3JH London, UK
- Metabolic Medicine Department, Royal Manchester Children Hospital NHS Foundation Trust, Manchester, UK
| | - Robin Lachmann
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Yusof Rahman
- Metabolic Medicine Department, St Thomas Hospital, London, UK
| | - Peter H. Robinson
- Paediatric Metabolic Medicine, Royal Hospital for Sick Children, Glasgow, UK
| | - Lesley MacPherson
- Neuroradiology Department, Birmingham Children’s Hospital NHS Foundation Trust, Birmingham, UK
| | - Katharine Foster
- Neuroradiology Department, Birmingham Children’s Hospital NHS Foundation Trust, Birmingham, UK
| | - W. Kling Chong
- Neuroradiology Department, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Deborah A. Ridout
- Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK
| | | | - Simon N. Waddington
- Gene Transfer Technology Group, Institute for Women’s Health, University College London, London, UK
- Wits/SAMRC Antiviral Gene Therapy Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Philippa B. Mills
- Genetics and Genomic Medicine Programme, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Paul Gissen
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, WC1N 3JH London, UK
- Genetics and Genomic Medicine Programme, Great Ormond Street Institute of Child Health, University College London, London, UK
- MRC Laboratory for Molecular Cell Biology, University College London, London, UK
| | - James E. Davison
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, WC1N 3JH London, UK
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Tanaka K, Nakamura K, Matsumoto S, Kido J, Mitsubuchi H, Ohura T, Endo F. Citrulline for urea cycle disorders in Japan. Pediatr Int 2017; 59:422-426. [PMID: 27613354 DOI: 10.1111/ped.13163] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 08/13/2016] [Accepted: 09/07/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND The amino acid l-citrulline is used as a therapeutic agent for urea cycle disorders (UCD) including ornithine transcarbamylase deficiency (OTCD), carbamoyl phosphate synthetase I deficiency (CPSD), and N-acetylglutamate synthase deficiency. There are few reports, however, on the use of l-citrulline in Japan and little consensus regarding the effects of l-citrulline. METHODS We conducted a questionnaire survey of patients undergoing l-citrulline treatment for a UCD to evaluate the current status of this therapy. The survey included patient background, details of l-citrulline treatment, clinical examination data, treatment, frequency of vomiting, and liver transplantation. RESULTS We retrospectively investigated 43 questionnaire respondents (OTCD, n = 33; CPSD, n = 10). The weight of male OTCD patients improved by +0.79 SD, and the ammonia level decreased by a mean of 44.3 μmol/L in all patients. The protein intake of all patients and of male OTCD patients increased by 0.14 g/kg/day and 0.17 g/kg/day, respectively. CONCLUSIONS l-Citrulline effectively reduced ammonia level, increased protein intake, and improved weight gain in UCD patients. l-Citrulline should be considered a standard therapy in OTCD and CPSD patients.
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Affiliation(s)
- Kenichi Tanaka
- Department of Pediatrics, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Kimitoshi Nakamura
- Department of Pediatrics, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Shirou Matsumoto
- Department of Pediatrics, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Jun Kido
- Department of Pediatrics, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Hiroshi Mitsubuchi
- Department of Pediatrics, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Toshihiro Ohura
- Department of Pediatrics, Sendai City Hospital, Sendai, Japan
| | - Fumio Endo
- Department of Pediatrics, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
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Diez-Fernandez C, Häberle J. Targeting CPS1 in the treatment of Carbamoyl phosphate synthetase 1 (CPS1) deficiency, a urea cycle disorder. Expert Opin Ther Targets 2017; 21:391-399. [PMID: 28281899 DOI: 10.1080/14728222.2017.1294685] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Carbamoyl phosphate synthetase 1 (CPS1) deficiency (CPS1D) is a rare autosomal recessive urea cycle disorder (UCD), which can lead to life-threatening hyperammonemia. Unless promptly treated, it can result in encephalopathy, coma and death, or intellectual disability in surviving patients. Over recent decades, therapies for CPS1D have barely improved leaving the management of these patients largely unchanged. Additionally, in many cases, current management (protein-restriction and supplementation with citrulline and/or arginine and ammonia scavengers) is insufficient for achieving metabolic stability, highlighting the importance of developing alternative therapeutic approaches. Areas covered: After describing UCDs and CPS1D, we give an overview of the structure- function of CPS1. We then describe current management and potential novel treatments including N-carbamoyl-L-glutamate (NCG), pharmacological chaperones, and gene therapy to treat hyperammonemia. Expert opinion: Probably, the first novel CPS1D therapies to reach the clinics will be the already commercial substance NCG, which is the standard treatment for N-acetylglutamate synthase deficiency and has been proven to rescue specific CPS1D mutations. Pharmacological chaperones and gene therapy are under development too, but these two technologies still have key challenges to be overcome. In addition, current experimental therapies will hopefully add further treatment options.
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Affiliation(s)
- Carmen Diez-Fernandez
- a Division of Metabolism , University Children's Hospital Zurich and Children's Research Center , Zurich , Switzerland
| | - Johannes Häberle
- a Division of Metabolism , University Children's Hospital Zurich and Children's Research Center , Zurich , Switzerland
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Stasyuk N, Gayda G, Yepremyan H, Stepien A, Gonchar M. Fluorometric enzymatic assay of l-arginine. SPECTROCHIMICA ACTA. PART A, MOLECULAR AND BIOMOLECULAR SPECTROSCOPY 2017; 170:184-190. [PMID: 27450117 DOI: 10.1016/j.saa.2016.07.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 07/07/2016] [Accepted: 07/09/2016] [Indexed: 06/06/2023]
Abstract
The enzymes of l-arginine (further - Arg) metabolism are promising tools for elaboration of selective methods for quantitative Arg analysis. In our study we propose an enzymatic method for Arg assay based on fluorometric monitoring of ammonia, a final product of Arg splitting by human liver arginase I (further - arginase), isolated from the recombinant yeast strain, and commercial urease. The selective analysis of ammonia (at 415nm under excitation at 360nm) is based on reaction with o-phthalaldehyde (OPA) in the presence of sulfite in alkali medium: these conditions permit to avoid the reaction of OPA with any amino acid. A linearity range of the fluorometric arginase-urease-OPA method is from 100nM to 6μМ with a limit of detection of 34nM Arg. The method was used for the quantitative determination of Arg in the pooled sample of blood serum. The obtained results proved to be in a good correlation with the reference enzymatic method and literature data. The proposed arginase-urease-OPA method being sensitive, economical, selective and suitable for both routine and micro-volume formats, can be used in clinical diagnostics for the simultaneous determination of Arg as well as urea and ammonia in serum samples.
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Affiliation(s)
- Nataliya Stasyuk
- Institute of Cell Biology, National Academy of Science of Ukraine, Drahomanov Str. 14/16, 79005 Lviv, Ukraine
| | - Galina Gayda
- Institute of Cell Biology, National Academy of Science of Ukraine, Drahomanov Str. 14/16, 79005 Lviv, Ukraine.
| | - Hasmik Yepremyan
- Scientific and Production Center "Armbiotechnology", National Academy of Sciences of Armenia, Armenia
| | - Agnieszka Stepien
- Department of Dietetics, Institute of Nursing and Health Sciences, Medical Faculty, University of Rzeszow, Al. mjr.W.Kopisto 2 a, 35-310 Rzeszów, Poland; Centre for Innovative Research in Medical and Natural Sciences, Medical Faculty of the University of Rzeszow, Warzywna 1A, 35-310 Rzeszów, Poland
| | - Mykhailo Gonchar
- Institute of Cell Biology, National Academy of Science of Ukraine, Drahomanov Str. 14/16, 79005 Lviv, Ukraine
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Neuropsychological functioning and health-related quality of life in pediatric liver disease: the sum of our perspectives is greater than each alone. Curr Opin Pediatr 2016; 28:644-52. [PMID: 27471904 DOI: 10.1097/mop.0000000000000405] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW The review will discuss current data on neuropsychological and health-related quality of life (HRQOL) outcomes in children with liver disease. Research has trickled in over the past 30 years, mostly in small, single-center studies with observational or retrospective design. As medical treatment has advanced, survival has improved dramatically, with the majority now living into adulthood. The focus is shifting toward more systematic exploration of functional outcomes. RECENT FINDINGS Contemporary cohorts provide evidence for increased prevalence of IQ deficits despite overall average means in children with end-stage liver disease and long after transplant. Recent studies explore specific neurocognitive domains and populations, such as pediatric acute liver failure and metabolic disorders. HRQOL is reduced in pediatric liver transplant recipients, even years later. Current research examines HRQOL in pediatric acute liver failure, infants with chronic liver disease, and specific diseases. A major psychosocial concern is the transition from pediatric to adult care, and the challenges in assessing transfer readiness. SUMMARY As research in functional outcomes becomes more sophisticated (more prospective, controlled, and multisite studies), richer data are available. The most comprehensive understanding of how children with liver disease fare is achieved by integrating perspectives into one picture painted by many.
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Husson MC, Schiff M, Fouilhoux A, Cano A, Dobbelaere D, Brassier A, Mention K, Arnoux JB, Feillet F, Chabrol B, Guffon N, Elie C, de Lonlay P. Efficacy and safety of i.v. sodium benzoate in urea cycle disorders: a multicentre retrospective study. Orphanet J Rare Dis 2016; 11:127. [PMID: 27663197 PMCID: PMC5034629 DOI: 10.1186/s13023-016-0513-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 09/06/2016] [Indexed: 12/30/2022] Open
Abstract
Background The efficacy and safety of intra-venous (i.v.) sodium benzoate for treating acute episodes of hyperammonemia in urea cycle enzyme disorders (UCD) is well known. However, published data do not provide a clear picture of the benefits and risks of this drug. We report a retrospective multicentre study on the use of i.v. sodium benzoate in patients treated for UCD between 2000 and 2010 in the 6 French reference centres for metabolic diseases. Results Sixty-one patients with UCDs - 22 ornithine transcarbamylase (20 confirmed, 2 suspected), 18 arginino-succinate synthetase, 15 carbamoyl phosphate synthetase, 3 arginosuccinate lyase, 1 arginase deficiency, 1 N-acetylglutamate synthetase, 1 HHH syndrome - required i.v. sodium benzoate over the course of 95 acute episodes (NH3 > 100 μmol/L or high-risk situations, i.e., gastroenteritis, surgery). Forty out of 61 patients experienced only one episode of decompensation (neonatal coma, 68.6 %). The most frequent cause of late decompensation was infection (55.5 %). A loading dose of i.v. sodium benzoate (median 250 mg/kg over 2 h) was administered for 41/95 acute episodes. The median maintenance dose was 246.1 mg/kg/day, administered via peripheral venous infusion in all cases except one via a central line. The total median duration of i.v. sodium benzoate treatment per episode was 2 days (0–13 days). The median durations of hospitalization in intensive care and metabolic units were 4 days (0–17 days) and 10 days (0–70 days), respectively. Eight patients died during the neonatal coma (n = 6) or surgery (n = 2). The median plasma ammonium level before treatment was 245.5 μmol/L (20.0–2274.0 μmol/L); it decreased to 40.0 μmol/L in patients who were alive (13.0–181.0 μmol/L) at the end of treatment with i.v. sodium benzoate. A decrease in ammonium level to ≤ 100 μmol/L was obtained in 92.8 % of episodes (64/69 of the episodes recorded for the 53 surviving patients). Five patients required another treatment for hyperammonemia (sodium phenylacetate + sodium benzoate, haemofiltration). Eighteen side effects were reported related to the i.v. infusion (local diffusion, oedema). Conclusion This 10-year retrospective study shows that i.v. sodium benzoate associated with an emergency regimen is an effective and safe treatment for acute episodes of UCD.
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Affiliation(s)
- Marie-Caroline Husson
- Etablissement Pharmaceutique des Hôpitaux de Paris, AGEPS, 7 rue du Fer à Moulin, Paris, 75005, France.
| | - Manuel Schiff
- Centre de Référence des Maladies Héréditaires du Métabolisme, Hôpital Robert-Debré, AP-HP, Paris, France
| | - Alain Fouilhoux
- Reference Centre for Inherited Metabolic Disorders, Hôpital Femme Mère-Enfant, Lyon, France
| | - Aline Cano
- Centre de Référence des Maladies Héréditaires du Métabolisme, CHU Timone Enfants, Marseille, France
| | - Dries Dobbelaere
- Centre de Référence des Maladies Héréditaires du Métabolisme, Hôpital Jeanne-de-Flandre, CHRU Lille, Lille, France
| | - Anais Brassier
- Reference Centre for Inherited Metabolic Disorders (MaMEA), Hôpital Necker-Enfants Malades, Institut Imagine, Université Paris Descartes, 149 rue de Sèvres, 75743, Paris, Cedex 15, France
| | - Karine Mention
- Centre de Référence des Maladies Héréditaires du Métabolisme, Hôpital Jeanne-de-Flandre, CHRU Lille, Lille, France
| | - Jean-Baptiste Arnoux
- Reference Centre for Inherited Metabolic Disorders (MaMEA), Hôpital Necker-Enfants Malades, Institut Imagine, Université Paris Descartes, 149 rue de Sèvres, 75743, Paris, Cedex 15, France
| | - François Feillet
- Centre de Référence des Maladies Héréditaires du Métabolisme, CHU de Nancy, Hôpital Brabois Enfants, Vandoeuvre-les-Nancy, France
| | - Brigitte Chabrol
- Centre de Référence des Maladies Héréditaires du Métabolisme, CHU Timone Enfants, Marseille, France
| | - Nathalie Guffon
- Reference Centre for Inherited Metabolic Disorders, Hôpital Femme Mère-Enfant, Lyon, France
| | - Caroline Elie
- URC/CIC Paris Centre, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, 75015, Paris, France
| | - Pascale de Lonlay
- Reference Centre for Inherited Metabolic Disorders (MaMEA), Hôpital Necker-Enfants Malades, Institut Imagine, Université Paris Descartes, 149 rue de Sèvres, 75743, Paris, Cedex 15, France
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Posset R, Garcia-Cazorla A, Valayannopoulos V, Teles EL, Dionisi-Vici C, Brassier A, Burlina AB, Burgard P, Cortès-Saladelafont E, Dobbelaere D, Couce ML, Sykut-Cegielska J, Häberle J, Lund AM, Chakrapani A, Schiff M, Walter JH, Zeman J, Vara R, Kölker S. Age at disease onset and peak ammonium level rather than interventional variables predict the neurological outcome in urea cycle disorders. J Inherit Metab Dis 2016; 39:661-672. [PMID: 27106216 DOI: 10.1007/s10545-016-9938-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 04/06/2016] [Accepted: 04/07/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Patients with urea cycle disorders (UCDs) have an increased risk of neurological disease manifestation. AIMS Determining the effect of diagnostic and therapeutic interventions on the neurological outcome. METHODS Evaluation of baseline, regular follow-up and emergency visits of 456 UCD patients prospectively followed between 2011 and 2015 by the E-IMD patient registry. RESULTS About two-thirds of UCD patients remained asymptomatic until age 12 days [i.e. the median age at diagnosis of patients identified by newborn screening (NBS)] suggesting a potential benefit of NBS. In fact, NBS lowered the age at diagnosis in patients with late onset of symptoms (>28 days), and a trend towards improved long-term neurological outcome was found for patients with argininosuccinate synthetase and lyase deficiency as well as argininemia identified by NBS. Three to 17 different drug combinations were used for maintenance therapy, but superiority of any single drug or specific drug combination above other combinations was not demonstrated. Importantly, non-interventional variables of disease severity, such as age at disease onset and peak ammonium level of the initial hyperammonemic crisis (cut-off level: 500 μmol/L) best predicted the neurological outcome. CONCLUSIONS Promising results of NBS for late onset UCD patients are reported and should be re-evaluated in a larger and more advanced age group. However, non-interventional variables affect the neurological outcome of UCD patients. Available evidence-based guideline recommendations are currently heterogeneously implemented into practice, leading to a high variability of drug combinations that hamper our understanding of optimised long-term and emergency treatment.
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Affiliation(s)
- Roland Posset
- Department of General Pediatrics, Division of Inherited Metabolic Diseases, University Children's Hospital Heidelberg, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany.
| | | | - Vassili Valayannopoulos
- Assistance Publique-Hôpitaux de Paris, Service de Maladies Metaboliques, Hôpital Necker-Enfants Malades, Paris, France
| | - Elisa Leão Teles
- Hospital de S. João, EPE, Unidade de Doenças Metabólicas, Serviço de Pediatria, Porto, Portugal
| | - Carlo Dionisi-Vici
- Ospedale Pediatrico Bambino Gésu, U.O.C. Patologia Metabolica, Rome, Italy
| | - Anaïs Brassier
- Assistance Publique-Hôpitaux de Paris, Service de Maladies Metaboliques, Hôpital Necker-Enfants Malades, Paris, France
| | - Alberto B Burlina
- Azienda Ospedaliera di Padova, U.O.C. Malattie Metaboliche Ereditarie, Padova, Italy
| | - Peter Burgard
- Department of General Pediatrics, Division of Inherited Metabolic Diseases, University Children's Hospital Heidelberg, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany
| | | | - Dries Dobbelaere
- Centre de Référence Maladies Héréditaires du Métabolisme de l'Enfant et de l'Adulte, Jeanne de Flandre Hospital, CHRU Lille, and RADEME EA 7364, Faculty of Medicine, University Lille 2, Lille, 59037, France
| | - Maria L Couce
- Metabolic Unit, Department of Pediatrics, Hospital Clinico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Johannes Häberle
- Division of Metabolism and Children's Research Centre, University Children's Hospital Zurich, Steinwiesstraße 75, CH-8032, Zurich, Switzerland
| | - Allan M Lund
- Centre for Inherited Metabolic Diseases, Department of Clinical Genetics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Anupam Chakrapani
- Birmingham Children's Hospital NHS Foundation Trust, Steelhouse Lane, Birmingham, B4 6NH, UK
- Metabolic Unit Great Ormond Street Hospital and Institute for Child Health, University College London, London, UK
| | - Manuel Schiff
- Hôpital Robert Debré, Reference Centre for Inborn Errors of Metabolism, APHP and Université Paris-Diderot, Paris, France
| | - John H Walter
- Manchester Academic Health Science Centre, Willink Biochemical Genetics Unit, Genetic Medicine, University of Manchester, Manchester, UK
| | - Jiri Zeman
- First Faculty of Medicine, Charles University and General University of Prague, Prague, Czech Republic
| | - Roshni Vara
- Evelina Children's Hospital, St Thomas' Hospital, London, UK
| | - Stefan Kölker
- Department of General Pediatrics, Division of Inherited Metabolic Diseases, University Children's Hospital Heidelberg, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany
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Huemer M, Carvalho DR, Brum JM, Ünal Ö, Coskun T, Weisfeld-Adams JD, Schrager NL, Scholl-Bürgi S, Schlune A, Donner MG, Hersberger M, Gemperle C, Riesner B, Ulmer H, Häberle J, Karall D. Clinical phenotype, biochemical profile, and treatment in 19 patients with arginase 1 deficiency. J Inherit Metab Dis 2016; 39:331-340. [PMID: 27038030 DOI: 10.1007/s10545-016-9928-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 03/10/2016] [Accepted: 03/15/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Arginase 1 (ARG1) deficiency is a rare urea cycle disorder (UCD). This hypothesis-generating study explored clinical phenotypes, metabolic profiles, molecular genetics, and treatment approaches in a cohort of children and adults with ARG1 deficiency to add to our understanding of the underlying pathophysiology. METHODS Clinical data were retrieved retrospectively from physicians using a questionnaire survey. Plasma aminoacids, guanidinoacetate (GAA), parameters indicating oxidative stress and nitric oxide (NO) synthesis as well as asymmetric dimethylarginine (ADMA) were measured at a single study site. RESULTS Nineteen individuals with ARG1 deficiency and 19 matched controls were included in the study. In patients, paraparesis, cognitive impairment, and seizures were significantly associated suggesting a shared underlying pathophysiology. In patients plasma GAA exceeded normal ranges and plasma ADMA was significantly elevated. Compared to controls, nitrate was significantly higher, and the nitrite:nitrate ratio significantly lower in subjects with ARG1 deficiency suggesting an advantage for NO synthesis by inducible NO synthase (iNOS) over endothelial NOS (eNOS). Logistic regression revealed no significant impact of any of the biochemical parameters (including arginine, nitrates, ADMA, GAA, oxidative stress) or protein restriction on long-term outcome. CONCLUSION Three main hypotheses which must be evaluated in a hypothesis driven confirmatory study are delineated from this study: 1) clinical manifestations in ARG1 deficiency are not correlated with arginine, protein intake, ADMA, nitrates or oxidative stress. 2) GAA is elevated and may be a marker or an active part of the pathophysiology of ARG1 deficiency. 3) Perturbations of NO metabolism merit future attention in ARG1 deficiency.
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Affiliation(s)
- Martina Huemer
- Division of Metabolic Diseases and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland.
- Radiz - Rare Disease Initiative Zurich, University Zurich, Zurich, Switzerland.
- Department of Paediatrics, Landeskrankenhaus Bregenz, Bregenz, Austria.
| | - Daniel R Carvalho
- Genetic Unit, SARAH Network of Rehabilitation Hospital, Brasilia, Brazil
| | - Jaime M Brum
- Molecular Pathology Department, Rede Sarah de Hospitais de Reabilitação, Brasilia, Brazil
| | - Özlem Ünal
- Department of Paediatrics, Division of Paediatric Nutrition and Metabolism, Hacettepe University Faculty of Medicine, Ankara, Turkey
- Ankara Children's Hospital, Haematology-Oncology Research and Education Hospital, Ankara, Turkey
| | - Turgay Coskun
- Department of Paediatrics, Division of Paediatric Nutrition and Metabolism, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - James D Weisfeld-Adams
- Program for Inherited Metabolic Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nina L Schrager
- Program for Inherited Metabolic Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sabine Scholl-Bürgi
- Clinic for Pediatrics I, Inherited Metabolic Disorders, Medical University of Innsbruck, Innsbruck, Austria
| | - Andrea Schlune
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - Markus G Donner
- Department of Gastroenterology, Hepatology and Infectious diseases, Heinrich Heine University, Düsseldorf, Germany
| | - Martin Hersberger
- Division of Clinical Chemistry and Biochemistry, University Children's Hospital Zurich, Zurich, Switzerland
| | - Claudio Gemperle
- Division of Clinical Chemistry and Biochemistry, University Children's Hospital Zurich, Zurich, Switzerland
| | - Brunhilde Riesner
- Department of Paediatrics, Landeskrankenhaus Bregenz, Bregenz, Austria
| | - Hanno Ulmer
- Department of Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Innsbruck, Austria
| | - Johannes Häberle
- Division of Metabolic Diseases and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- Radiz - Rare Disease Initiative Zurich, University Zurich, Zurich, Switzerland
| | - Daniela Karall
- Clinic for Pediatrics I, Inherited Metabolic Disorders, Medical University of Innsbruck, Innsbruck, Austria
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Maillot F, Blasco H, Lioger B, Bigot A, Douillard C. [Diagnosis and treatment of urea cycle disorders in adult patients]. Rev Med Interne 2016; 37:680-684. [PMID: 27032484 DOI: 10.1016/j.revmed.2016.02.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 11/19/2015] [Accepted: 02/26/2016] [Indexed: 12/30/2022]
Abstract
Urea cycle disorders (UCDs) are inborn errors of metabolism in which the clinical picture is mostly due to ammonia intoxication. UCD onset may be observed at any age. Acute decompensations of UCDs include neuro-psychiatric symptoms such as headache, confusion, convulsions, ataxia, agitation or delirium, as well as digestive symptoms, namely nausea and vomiting along with abdominal pain. Acute decompensations may lead to an irreversible coma in the absence of specific therapy. The first step is to measure promptly ammonemia in such patients, and start appropriate therapy on an emergency basis.
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Affiliation(s)
- F Maillot
- Service de médecine interne, centre de compétences des maladies héréditaires du métabolisme, hôpital Bretonneau, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours cedex 9, France; Université François-Rabelais, Tours, France; Inserm U1069, Tours, France.
| | - H Blasco
- Université François-Rabelais, Tours, France; Service de biochimie, CHRU de Tours, Tours, France; Inserm U930, Tours, France
| | - B Lioger
- Service de médecine interne, centre de compétences des maladies héréditaires du métabolisme, hôpital Bretonneau, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours cedex 9, France; Université François-Rabelais, Tours, France
| | - A Bigot
- Service de médecine interne, centre de compétences des maladies héréditaires du métabolisme, hôpital Bretonneau, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours cedex 9, France; Université François-Rabelais, Tours, France
| | - C Douillard
- Centre de référence des maladies héréditaires du métabolisme, CHRU de Lille, Lille, France
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48
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Kölker S, Valayannopoulos V, Burlina AB, Sykut-Cegielska J, Wijburg FA, Teles EL, Zeman J, Dionisi-Vici C, Barić I, Karall D, Arnoux JB, Avram P, Baumgartner MR, Blasco-Alonso J, Boy SPN, Rasmussen MB, Burgard P, Chabrol B, Chakrapani A, Chapman K, Cortès I Saladelafont E, Couce ML, de Meirleir L, Dobbelaere D, Furlan F, Gleich F, González MJ, Gradowska W, Grünewald S, Honzik T, Hörster F, Ioannou H, Jalan A, Häberle J, Haege G, Langereis E, de Lonlay P, Martinelli D, Matsumoto S, Mühlhausen C, Murphy E, de Baulny HO, Ortez C, Pedrón CC, Pintos-Morell G, Pena-Quintana L, Ramadža DP, Rodrigues E, Scholl-Bürgi S, Sokal E, Summar ML, Thompson N, Vara R, Pinera IV, Walter JH, Williams M, Lund AM, Garcia-Cazorla A. The phenotypic spectrum of organic acidurias and urea cycle disorders. Part 2: the evolving clinical phenotype. J Inherit Metab Dis 2015; 38:1059-74. [PMID: 25875216 DOI: 10.1007/s10545-015-9840-x] [Citation(s) in RCA: 153] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 01/21/2015] [Accepted: 01/26/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND The disease course and long-term outcome of patients with organic acidurias (OAD) and urea cycle disorders (UCD) are incompletely understood. AIMS To evaluate the complex clinical phenotype of OAD and UCD patients at different ages. RESULTS Acquired microcephaly and movement disorders were common in OAD and UCD highlighting that the brain is the major organ involved in these diseases. Cardiomyopathy [methylmalonic (MMA) and propionic aciduria (PA)], prolonged QTc interval (PA), optic nerve atrophy [MMA, isovaleric aciduria (IVA)], pancytopenia (PA), and macrocephaly [glutaric aciduria type 1 (GA1)] were exclusively found in OAD patients, whereas hepatic involvement was more frequent in UCD patients, in particular in argininosuccinate lyase (ASL) deficiency. Chronic renal failure was often found in MMA, with highest frequency in mut(0) patients. Unexpectedly, chronic renal failure was also observed in adolescent and adult patients with GA1 and ASL deficiency. It had a similar frequency in patients with or without a movement disorder suggesting different pathophysiology. Thirteen patients (classic OAD: 3, UCD: 10) died during the study interval, ten of them during the initial metabolic crisis in the newborn period. Male patients with late-onset ornithine transcarbamylase deficiency were presumably overrepresented in the study population. CONCLUSIONS Neurologic impairment is common in OAD and UCD, whereas the involvement of other organs (heart, liver, kidneys, eyes) follows a disease-specific pattern. The identification of unexpected chronic renal failure in GA1 and ASL deficiency emphasizes the importance of a systematic follow-up in patients with rare diseases.
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Affiliation(s)
- Stefan Kölker
- Department of General Pediatrics, Division of Inherited Metabolic Diseases, University Children's Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany.
| | - Vassili Valayannopoulos
- Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Reference Center for Inherited Metabolic Disease, Necker-Enfants Malades University Hospital and IMAGINE Institute, Paris, France
| | - Alberto B Burlina
- Azienda Ospedaliera di Padova, U.O.C. Malattie Metaboliche Ereditarie, Padova, Italy
| | | | - Frits A Wijburg
- Department of Pediatrics, Academisch Medisch Centrum, Amsterdam, Netherlands
| | - Elisa Leão Teles
- Unidade de Doenças Metabólicas, Serviço de Pediatria, Hospital de S. João, EPE, Porto, Portugal
| | - Jiri Zeman
- First Faculty of Medicine Charles University and General University of Prague, Prague, Czech Republic
| | - Carlo Dionisi-Vici
- Ospedale Pediatrico Bambino Gésu, U.O.C. Patologia Metabolica, Rome, Italy
| | - Ivo Barić
- School of Medicine University Hospital Center Zagreb and University of Zagreb, Zagreb, Croatia
| | - Daniela Karall
- Medical University of Innsbruck, Clinic for Pediatrics I, Inherited Metabolic Disorders, Innsbruck, Austria
| | - Jean-Baptiste Arnoux
- Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Reference Center for Inherited Metabolic Disease, Necker-Enfants Malades University Hospital and IMAGINE Institute, Paris, France
| | - Paula Avram
- Institute of Mother and Child Care "Alfred Rusescu", Bucharest, Romania
| | - Matthias R Baumgartner
- Division of Metabolism and Children's Research Centre, University Children's Hospital Zurich, Steinwiesstraße 75, 8032, Zurich, Switzerland
| | | | - S P Nikolas Boy
- Department of General Pediatrics, Division of Inherited Metabolic Diseases, University Children's Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Marlene Bøgehus Rasmussen
- Centre for Inherited Metabolic Diseases, Department of Clinical Genetics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Peter Burgard
- Department of General Pediatrics, Division of Inherited Metabolic Diseases, University Children's Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Brigitte Chabrol
- Centre de Référence des Maladies Héréditaires du Métabolisme, Service de Neurologie, Hôpital d'Enfants, CHU Timone, Marseilles, France
| | - Anupam Chakrapani
- Birmingham Children's Hospital NHS Foundation Trust, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Kimberly Chapman
- Children's National Medical Center, 111 Michigan Avenue, N.W., Washington, DC, 20010, USA
| | | | - Maria L Couce
- Metabolic Unit, Department of Pediatrics, Hospital Clinico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Dries Dobbelaere
- Centre de Référence des Maladies Héréditaires du Métabolisme de l'Enfant et de l'Adulte, Hôpital Jeanne de Flandre, Lille, France
| | - Francesca Furlan
- Azienda Ospedaliera di Padova, U.O.C. Malattie Metaboliche Ereditarie, Padova, Italy
| | - Florian Gleich
- Department of General Pediatrics, Division of Inherited Metabolic Diseases, University Children's Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | | | - Wanda Gradowska
- Department of Laboratory Diagnostics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Stephanie Grünewald
- Metabolic Unit Great Ormond Street Hospital and Institute for Child Health, University College London, London, UK
| | - Tomas Honzik
- First Faculty of Medicine Charles University and General University of Prague, Prague, Czech Republic
| | - Friederike Hörster
- Department of General Pediatrics, Division of Inherited Metabolic Diseases, University Children's Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Hariklea Ioannou
- 1st Pediatric Department, Metabolic Laboratory, General Hospital of Thessaloniki 'Hippocration', Thessaloniki, Greece
| | - Anil Jalan
- N.I.R.M.A.N., Om Rachna Society, Vashi, Navi Mumbai, Mumbai, India
| | - Johannes Häberle
- Division of Metabolism and Children's Research Centre, University Children's Hospital Zurich, Steinwiesstraße 75, 8032, Zurich, Switzerland
| | - Gisela Haege
- Department of General Pediatrics, Division of Inherited Metabolic Diseases, University Children's Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Eveline Langereis
- Department of Pediatrics, Academisch Medisch Centrum, Amsterdam, Netherlands
| | - Pascale de Lonlay
- Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Reference Center for Inherited Metabolic Disease, Necker-Enfants Malades University Hospital and IMAGINE Institute, Paris, France
| | - Diego Martinelli
- Ospedale Pediatrico Bambino Gésu, U.O.C. Patologia Metabolica, Rome, Italy
| | - Shirou Matsumoto
- Department of Pediatrics, Kumamoto University Hospital, Kumamoto City, Japan
| | - Chris Mühlhausen
- Universitätsklinikum Hamburg-Eppendorf, Klinik für Kinder- und Jugendmedizin, Hamburg, Germany
| | - Elaine Murphy
- National Hospital for Neurology and Neurosurgery, Charles Dent Metabolic Unit, London, UK
| | | | - Carlos Ortez
- Hospital San Joan de Deu, Servicio de Neurologia and CIBERER, ISCIII, Barcelona, Spain
| | - Consuelo C Pedrón
- Department of Pediatrics, Metabolic Diseases Unit, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Guillem Pintos-Morell
- Department of Pediatrics, Hospital Universitari Germans Trias I Pujol, Badalona, Spain
| | | | | | - Esmeralda Rodrigues
- Unidade de Doenças Metabólicas, Serviço de Pediatria, Hospital de S. João, EPE, Porto, Portugal
| | - Sabine Scholl-Bürgi
- Medical University of Innsbruck, Clinic for Pediatrics I, Inherited Metabolic Disorders, Innsbruck, Austria
| | - Etienne Sokal
- Cliniques Universitaires St Luc, Université Catholique de Louvain, Service Gastroentérologie and Hépatologie Pédiatrique, Bruxelles, Belgium
| | - Marshall L Summar
- Children's National Medical Center, 111 Michigan Avenue, N.W., Washington, DC, 20010, USA
| | - Nicholas Thompson
- Metabolic Unit Great Ormond Street Hospital and Institute for Child Health, University College London, London, UK
| | - Roshni Vara
- Evelina Children's Hospital, St Thomas' Hospital, London, United Kingdom
| | | | - John H Walter
- Manchester Academic Health Science Centre, University of Manchester, Willink Biochemical Genetics Unit, Genetic Medicine, Manchester, UK
| | - Monique Williams
- Erasmus MC-Sophia Kinderziekenhuis, Erasmus Universiteit Rotterdam, Rotterdam, Netherlands
| | - Allan M Lund
- Centre for Inherited Metabolic Diseases, Department of Clinical Genetics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Kölker S, Garcia-Cazorla A, Valayannopoulos V, Lund AM, Burlina AB, Sykut-Cegielska J, Wijburg FA, Teles EL, Zeman J, Dionisi-Vici C, Barić I, Karall D, Augoustides-Savvopoulou P, Aksglaede L, Arnoux JB, Avram P, Baumgartner MR, Blasco-Alonso J, Chabrol B, Chakrapani A, Chapman K, I Saladelafont EC, Couce ML, de Meirleir L, Dobbelaere D, Dvorakova V, Furlan F, Gleich F, Gradowska W, Grünewald S, Jalan A, Häberle J, Haege G, Lachmann R, Laemmle A, Langereis E, de Lonlay P, Martinelli D, Matsumoto S, Mühlhausen C, de Baulny HO, Ortez C, Peña-Quintana L, Ramadža DP, Rodrigues E, Scholl-Bürgi S, Sokal E, Staufner C, Summar ML, Thompson N, Vara R, Pinera IV, Walter JH, Williams M, Burgard P. The phenotypic spectrum of organic acidurias and urea cycle disorders. Part 1: the initial presentation. J Inherit Metab Dis 2015; 38:1041-57. [PMID: 25875215 DOI: 10.1007/s10545-015-9839-3] [Citation(s) in RCA: 165] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 01/21/2015] [Accepted: 01/26/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND The clinical presentation of patients with organic acidurias (OAD) and urea cycle disorders (UCD) is variable; symptoms are often non-specific. AIMS/METHODS To improve the knowledge about OAD and UCD the E-IMD consortium established a web-based patient registry. RESULTS We registered 795 patients with OAD (n = 452) and UCD (n = 343), with ornithine transcarbamylase (OTC) deficiency (n = 196), glutaric aciduria type 1 (GA1; n = 150) and methylmalonic aciduria (MMA; n = 149) being the most frequent diseases. Overall, 548 patients (69 %) were symptomatic. The majority of them (n = 463) presented with acute metabolic crisis during (n = 220) or after the newborn period (n = 243) frequently demonstrating impaired consciousness, vomiting and/or muscular hypotonia. Neonatal onset of symptoms was most frequent in argininosuccinic synthetase and lyase deficiency and carbamylphosphate 1 synthetase deficiency, unexpectedly low in male OTC deficiency, and least frequently in GA1 and female OTC deficiency. For patients with MMA, propionic aciduria (PA) and OTC deficiency (male and female), hyperammonemia was more severe in metabolic crises during than after the newborn period, whereas metabolic acidosis tended to be more severe in MMA and PA patients with late onset of symptoms. Symptomatic patients without metabolic crises (n = 94) often presented with a movement disorder, mental retardation, epilepsy and psychiatric disorders (the latter in UCD only). CONCLUSIONS The initial presentation varies widely in OAD and UCD patients. This is a challenge for rapid diagnosis and early start of treatment. Patients with a sepsis-like neonatal crisis and those with late-onset of symptoms are both at risk of delayed or missed diagnosis.
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Affiliation(s)
- Stefan Kölker
- Department of General Pediatrics, Division of Inherited Metabolic Diseases, University Children's Hospital Heidelberg, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany.
| | | | - Vassili Valayannopoulos
- Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Reference Center for Inherited Metabolic Disease, Necker-Enfants Malades University Hospital and IMAGINE Institute, Paris, France
| | - Allan M Lund
- Centre for Inherited Metabolic Diseases, Department of Clinical Genetics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Alberto B Burlina
- U.O.C. Malattie Metaboliche Ereditarie, Azienda Ospedaliera di Padova, Padova, Italy
| | | | - Frits A Wijburg
- Department of Pediatrics, Academisch Medisch Centrum, Amsterdam, Netherlands
| | - Elisa Leão Teles
- Unidade de Doenças Metabólicas, Serviço de Pediatria, Hospital de S. João, EPE, Porto, Portugal
| | - Jiri Zeman
- First Faculty of Medicine, Charles University and General University of Prague, Prague, Czech Republic
| | - Carlo Dionisi-Vici
- U.O.C. Patologia Metabolica, Ospedale Pediatrico Bambino Gésu, Rome, Italy
| | - Ivo Barić
- School of Medicine, University Hospital Center Zagreb and University of Zagreb, Zagreb, Croatia
| | - Daniela Karall
- Clinic for Pediatrics I, Inherited Metabolic Disorders, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Lise Aksglaede
- Centre for Inherited Metabolic Diseases, Department of Clinical Genetics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jean-Baptiste Arnoux
- Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Reference Center for Inherited Metabolic Disease, Necker-Enfants Malades University Hospital and IMAGINE Institute, Paris, France
| | - Paula Avram
- Institute of Mother and Child Care "Alfred Rusescu", Bucharest, Romania
| | - Matthias R Baumgartner
- Division of Metabolism and Children's Research Centre, University Children's Hospital Zurich, Steinwiesstraße 75, CH-8032, Zurich, Switzerland
| | | | - Brigitte Chabrol
- Centre de Référence des Maladies Héréditaires du Métabolisme, Service de Neurologie, Hôpital d'Enfants, CHU Timone, Marseilles, France
| | - Anupam Chakrapani
- Birmingham Children's Hospital NHS Foundation Trust, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Kimberly Chapman
- Children's National Medical Center, 111 Michigan Avenue, N.W., Washington, DC, 20010, USA
| | | | - Maria L Couce
- Metabolic Unit, Department of Pediatrics, Hospital Clinico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Dries Dobbelaere
- Centre de Référence des Maladies Héréditaires du Métabolisme de l'Enfant et de l'Adulte, Hôpital Jeanne de Flandre, Lille, France
| | - Veronika Dvorakova
- First Faculty of Medicine, Charles University and General University of Prague, Prague, Czech Republic
| | - Francesca Furlan
- U.O.C. Malattie Metaboliche Ereditarie, Azienda Ospedaliera di Padova, Padova, Italy
| | - Florian Gleich
- Department of General Pediatrics, Division of Inherited Metabolic Diseases, University Children's Hospital Heidelberg, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany
| | - Wanda Gradowska
- Department of Laboratory Diagnostics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Stephanie Grünewald
- Metabolic Unit Great Ormond Street Hospital and Institute for Child Health, University College London, London, UK
| | - Anil Jalan
- N.I.R.M.A.N., Om Rachna Society, Vashi, Navi Mumbai, Mumbai, India
| | - Johannes Häberle
- Division of Metabolism and Children's Research Centre, University Children's Hospital Zurich, Steinwiesstraße 75, CH-8032, Zurich, Switzerland
| | - Gisela Haege
- Department of General Pediatrics, Division of Inherited Metabolic Diseases, University Children's Hospital Heidelberg, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany
| | - Robin Lachmann
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Alexander Laemmle
- Division of Metabolism and Children's Research Centre, University Children's Hospital Zurich, Steinwiesstraße 75, CH-8032, Zurich, Switzerland
| | - Eveline Langereis
- Department of Pediatrics, Academisch Medisch Centrum, Amsterdam, Netherlands
| | - Pascale de Lonlay
- Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Reference Center for Inherited Metabolic Disease, Necker-Enfants Malades University Hospital and IMAGINE Institute, Paris, France
| | - Diego Martinelli
- U.O.C. Patologia Metabolica, Ospedale Pediatrico Bambino Gésu, Rome, Italy
| | - Shirou Matsumoto
- Department of Pediatrics, Kumamoto University Hospital, Kumamoto City, Japan
| | - Chris Mühlhausen
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | - Carlos Ortez
- Servicio de Neurologia and CIBERER, ISCIII, Hospital San Joan de Deu, Barcelona, Spain
| | - Luis Peña-Quintana
- Hospital Universitario Materno-Infantil de Canarias, Unit of Pediatric Gastroenterology, Hepatology and Nutrition, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | | | - Esmeralda Rodrigues
- Unidade de Doenças Metabólicas, Serviço de Pediatria, Hospital de S. João, EPE, Porto, Portugal
| | - Sabine Scholl-Bürgi
- Clinic for Pediatrics I, Inherited Metabolic Disorders, Medical University of Innsbruck, Innsbruck, Austria
| | - Etienne Sokal
- Service Gastroentérologie and Hépatologie Pédiatrique, Cliniques Universitaires St Luc, Université Catholique de Louvain, Bruxelles, Belgium
| | - Christian Staufner
- Department of General Pediatrics, Division of Inherited Metabolic Diseases, University Children's Hospital Heidelberg, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany
| | - Marshall L Summar
- Children's National Medical Center, 111 Michigan Avenue, N.W., Washington, DC, 20010, USA
| | - Nicholas Thompson
- Metabolic Unit Great Ormond Street Hospital and Institute for Child Health, University College London, London, UK
| | - Roshni Vara
- Evelina Children's Hospital, St Thomas' Hospital, London, UK
| | | | - John H Walter
- Manchester Academic Health Science Centre, Willink Biochemical Genetics Unit, Genetic Medicine, University of Manchester, Manchester, UK
| | - Monique Williams
- Erasmus MC-Sophia Kinderziekenhuis, Erasmus Universiteit Rotterdam, Rotterdam, Netherlands
| | - Peter Burgard
- Department of General Pediatrics, Division of Inherited Metabolic Diseases, University Children's Hospital Heidelberg, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany
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Hegarty R, Hadzic N, Gissen P, Dhawan A. Inherited metabolic disorders presenting as acute liver failure in newborns and young children: King's College Hospital experience. Eur J Pediatr 2015; 174:1387-92. [PMID: 25902754 DOI: 10.1007/s00431-015-2540-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 04/04/2015] [Accepted: 04/08/2015] [Indexed: 11/27/2022]
Abstract
UNLABELLED Acute liver failure (ALF) in children is a rare condition that is often fatal without liver transplantation. The diagnostic work-up is complex, and the etiology is unidentified in up to half of patients, making decisions like therapeutic transplantation extremely difficult. We collected clinical, laboratory, and outcome data on all patients under 5 years of age who were admitted between January 2001 and December 2011 to King's College Hospital with ALF secondary to an inherited metabolic disease (IMD), a common cause of pediatric acute liver failure. Thirty-six of 127 children with ALF had a metabolic etiology: galactosemia (17); mitochondrial respiratory chain disorder (MRCD, 7); ornithine transcarbamylase (OTC) deficiency (4); tyrosinemia type 1 (4); Niemann-Pick disease type C (NPC, 3); and congenital disorder of glycosylation type 1b (1). Seven children died: MRCD (4) and NPC (3). Four children were transplanted: OTC deficiency (1) and MRCD (3). Fifteen of 25 children followed up showed evidence of developmental delay. CONCLUSION IMD is the most common group of disorders in this age group; indeterminate cases may yet include undiagnosed metabolic disorders; the overall survival rate is good but largely depends on diagnosis, while developmental outcome of the surviving patients is less favorable. WHAT IS KNOWN • Up to half of children with ALF may be undiagnosed. • IMD is a common cause of pediatric acute liver failure. What is New: • Initial diagnostic clues may be gathered from the child's age and laboratory parameters. • Survival of children with IMD-related ALF is good, but developmental outcome is less favorable. • In the future, novel sequencing methods will aid in the diagnosis of disorders in which therapeutic decisions depend upon.
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Affiliation(s)
- Robert Hegarty
- Pediatric Liver Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK.
| | - Nedim Hadzic
- Pediatric Liver Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK.
| | - Paul Gissen
- Metabolic Medicine Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.
| | - Anil Dhawan
- Pediatric Liver Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK.
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