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Vuković T, Kuek LE, Yu B, Makris G, Häberle J. The therapeutic landscape of citrin deficiency. J Inherit Metab Dis 2024; 47:1157-1174. [PMID: 39021261 PMCID: PMC11586593 DOI: 10.1002/jimd.12768] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 05/28/2024] [Accepted: 05/28/2024] [Indexed: 07/20/2024]
Abstract
Citrin deficiency (CD) is a recessive, liver disease caused by sequence variants in the SLC25A13 gene encoding a mitochondrial aspartate-glutamate transporter. CD manifests as different age-dependent phenotypes and affects crucial hepatic metabolic pathways including malate-aspartate-shuttle, glycolysis, gluconeogenesis, de novo lipogenesis and the tricarboxylic acid and urea cycles. Although the exact pathophysiology of CD remains unclear, impaired use of glucose and fatty acids as energy sources due to NADH shuttle defects and PPARα downregulation, respectively, indicates evident energy deficit in CD hepatocytes. The present review summarizes current trends on available and potential treatments for CD. Baseline recommendation for CD patients is dietary management, often already present as a self-selected food preference, that includes protein and fat-rich food, and avoidance of excess carbohydrates. At present, liver transplantation remains the sole curative option for severe CD cases. Our extensive literature review indicated medium-chain triglycerides (MCT) as the most widely used CD treatment in all age groups. MCT can effectively improve symptoms across disease phenotypes by rapidly supplying energy to the liver, restoring redox balance and inducing lipogenesis. In contrast, sodium pyruvate restored glycolysis and displayed initial preclinical promise, with however limited efficacy in adult CD patients. Ursodeoxycholic acid, nitrogen scavengers and L-arginine treatments effectively address specific pathophysiological aspects such as cholestasis and hyperammonemia and are commonly administered in combination with other drugs. Finally, future possibilities including restoring redox balance, amino acid supplementation, enhancing bioenergetics, improving ureagenesis and mRNA/DNA-based gene therapy are also discussed.
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Affiliation(s)
- Toni Vuković
- University Children's Hospital Zurich and Children's Research CenterUniversity of ZurichZurichSwitzerland
| | | | | | - Georgios Makris
- University Children's Hospital Zurich and Children's Research CenterUniversity of ZurichZurichSwitzerland
| | - Johannes Häberle
- University Children's Hospital Zurich and Children's Research CenterUniversity of ZurichZurichSwitzerland
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Redant S, Empain A, Mugisha A, Kamgang P, Attou R, Honoré PM, De Bels D. Management of late onset urea cycle disorders-a remaining challenge for the intensivist? Ann Intensive Care 2021; 11:2. [PMID: 33409766 PMCID: PMC7788146 DOI: 10.1186/s13613-020-00797-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 12/26/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Hyperammonemia caused by a disorder of the urea cycle is a rare cause of metabolic encephalopathy that may be underdiagnosed by the adult intensivists because of its rarity. Urea cycle disorders are autosomal recessive diseases except for ornithine transcarbamylase deficiency (OTCD) that is X-linked. Optimal treatment is crucial to improve prognosis. Main body We systematically reviewed cases reported in the literature on hyperammonemia in adulthood. We used the US National Library of Medicine Pubmed search engine since 2009. The two main causes are ornithine transcarbamylase deficiency followed by type II citrullinemia. Diagnosis by the intensivist remains very challenging therefore delaying treatment and putting patients at risk of fatal cerebral edema. Treatment consists in adapted nutrition, scavenging agents and dialysis. As adults are more susceptible to hyperammonemia, emergent hemodialysis is mandatory before referral to a reference center if ammonia levels are above 200 µmol/l as the risk of cerebral edema is then above 55%. Definitive therapy in urea cycle abnormalities is liver transplantation. CONCLUSION Awareness of urea cycle disorders in adults intensive care units can optimize early management and accordingly dramatically improve prognosis. By preventing hyperammonemia to induce brain edema and herniation leading to death.
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Affiliation(s)
- S Redant
- Department of Intensive Care, Université Libre de Bruxelles (ULB), CHU Brugmann-Brugmann University Hospital, 4, Place Arthur Van Gehuchten, 1020, Brussels, Belgium
| | - A Empain
- Department of Metabolic Diseases, Hôpital universitaire des enfants reine Fabiola, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - A Mugisha
- Department of Intensive Care, Université Libre de Bruxelles (ULB), CHU Brugmann-Brugmann University Hospital, 4, Place Arthur Van Gehuchten, 1020, Brussels, Belgium
| | - P Kamgang
- Department of Internal Medicine, Brugmann University Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - R Attou
- Department of Intensive Care, Université Libre de Bruxelles (ULB), CHU Brugmann-Brugmann University Hospital, 4, Place Arthur Van Gehuchten, 1020, Brussels, Belgium
| | - P M Honoré
- Department of Intensive Care, Université Libre de Bruxelles (ULB), CHU Brugmann-Brugmann University Hospital, 4, Place Arthur Van Gehuchten, 1020, Brussels, Belgium.
| | - D De Bels
- Department of Intensive Care, Université Libre de Bruxelles (ULB), CHU Brugmann-Brugmann University Hospital, 4, Place Arthur Van Gehuchten, 1020, Brussels, Belgium
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Unita S, Hirashima N, Shimada M, Tsunekawa T, Tanaka D, Kondo T, Urata N, Kondo H, Saito M, Iwase H, Ito S, Togawa T, Saitoh S, Tanaka Y. Successful treatment of adult-onset type II citrullinemia with a low-carbohydrate diet and L-arginine after DNA analysis produced a definitive diagnosis. Clin J Gastroenterol 2020; 13:823-833. [PMID: 31898207 DOI: 10.1007/s12328-019-01083-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 12/12/2019] [Indexed: 10/25/2022]
Abstract
A 60-year-old male, who exhibited finger tremors, obnubilation, and hyperammonemia (409 μg/dL), was admitted to our hospital. Initially, we suspected that a portosystemic shunt had caused his hyperammonemia. However, his symptoms did not improve after balloon-occluded retrograde transvenous obliteration. He was subsequently found to have some peculiar eating habits, including a fondness for bean curd and peanuts, and an aversion to alcohol and sweets. Furthermore, marked citrullinemia (454.2 nmol/mL) was revealed, which led us to suspect adult-onset type II citrullinemia (CTLN2). DNA analysis of the patient and his mother, son, and daughter confirmed that he was homozygous for the c.852_855del mutation in the SLC25A13 gene, and his relatives were heterozygous for the c.852_855del mutation, which led to a definitive diagnosis. A low-carbohydrate diet and the administration of L-arginine ameliorated his symptoms. It is important to be aware that CTLN2 can occur in elderly patients. Thus, patients who exhibit symptoms of CTLN2 should be interviewed about their dietary habits and subjected to plasma amino acid analysis.In this report, we consider the metabolic disorders seen in citrin deficiency and the associated compensatory mechanisms in relation to the clinical features and treatment of CTLN2.
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Affiliation(s)
- Satoshi Unita
- Department of Gastroenterology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan.
| | - Noboru Hirashima
- Department of Gastroenterology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Masaaki Shimada
- Department of Gastroenterology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Takuya Tsunekawa
- Department of Gastroenterology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Daiki Tanaka
- Department of Gastroenterology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Takashi Kondo
- Department of Gastroenterology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Noboru Urata
- Department of Gastroenterology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Hisashi Kondo
- Department of Gastroenterology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Masashi Saito
- Department of Gastroenterology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Hiroaki Iwase
- Department of Gastroenterology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Shogo Ito
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takao Togawa
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Shinji Saitoh
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yasuhito Tanaka
- Department of Virology and Liver Unit, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Tan A, Florman SS, Schiano TD. Genetic, hematological, and immunological disorders transmissible with liver transplantation. Liver Transpl 2017; 23:663-678. [PMID: 28240807 DOI: 10.1002/lt.24755] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 02/14/2017] [Indexed: 12/08/2022]
Abstract
It is well recognized that solid organ transplantation can transmit bacterial infection and chronic viral hepatitis as well as certain cancers. As indications for liver transplantation (LT) have expanded, it has been used to treat and even cure certain genetic cholestatic disorders, urea cycle defects, and coagulation abnormalities; many of these conditions are potentially transmissible with LT as well. It is important for clinicians and transplant patients to be aware of these potentially transmissible conditions as unexplained post-LT complications can sometimes be related to donor transmission of disease and thus should prompt a thorough exploration of the donor allograft history. Herein, we will review the reported genetic, metabolic, hematologic, and immunological disorders that are transmissible with LT and describe clinical scenarios in which these cases have occurred, such as in inadvertent or recognized transplantation of a diseased organ, domino transplantation, and with living related liver donation. Liver Transplantation 23 663-678 2017 AASLD.
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Affiliation(s)
- Amy Tan
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sander S Florman
- Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY
| | - Thomas D Schiano
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.,Division of Liver Diseases, Mount Sinai Medical Center, New York, NY.,Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY
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Schielke A, Conti F, Goumard C, Perdigao F, Calmus Y, Scatton O. Liver transplantation using grafts with rare metabolic disorders. Dig Liver Dis 2015; 47:261-70. [PMID: 25498135 DOI: 10.1016/j.dld.2014.11.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 10/26/2014] [Accepted: 11/06/2014] [Indexed: 12/11/2022]
Abstract
Metabolic diseases that involve the liver represent a heterogeneous group of disorders. Apart from the metabolic defect, the subject's liver functions may be normal. With the increasing need for organs, livers from donors with metabolic diseases other than familial amyloid polyneuropathy might be possibly used for transplantation. However, whether such livers qualify as grafts and how they might impact recipient outcome are still unanswered questions. This review of the literature summarizes current experience in the use of such grafts in the context of cadaveric, domino, and living-related liver transplantation.
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Affiliation(s)
- Astrid Schielke
- AP-HP, Department of Hepatobiliary Surgery and Liver Transplantation, Hôpital La Pitié - Salpêtrière, Paris, France.
| | - Filomena Conti
- AP-HP, Department of Hepatogastroenterology, Hôpital La Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, France; Université Pierre et Marie Curie, 4 Place Jussieu, Paris, France.
| | - Claire Goumard
- AP-HP, Department of Hepatobiliary Surgery and Liver Transplantation, Hôpital La Pitié - Salpêtrière, Paris, France.
| | - Fabiano Perdigao
- AP-HP, Department of Hepatobiliary Surgery and Liver Transplantation, Hôpital La Pitié - Salpêtrière, Paris, France.
| | - Yvon Calmus
- AP-HP, Department of Hepatogastroenterology, Hôpital La Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, France; Université Pierre et Marie Curie, 4 Place Jussieu, Paris, France.
| | - Olivier Scatton
- AP-HP, Department of Hepatobiliary Surgery and Liver Transplantation, Hôpital La Pitié - Salpêtrière, Paris, France; Université Pierre et Marie Curie, 4 Place Jussieu, Paris, France.
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Liver transplantation versus conservative treatment for adult-onset type II citrullinemia: our experience and a review of the literature. Transplant Proc 2014; 45:3432-7. [PMID: 24182831 DOI: 10.1016/j.transproceed.2013.06.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Revised: 05/15/2013] [Accepted: 06/18/2013] [Indexed: 12/26/2022]
Abstract
Adult-onset type II citrullinemia (CTLN2), an autosomal recessive disorder caused by a mutation in the SLC25A13 gene, is characterized by increased serum citrulline and ammonia levels. Patients with CTLN2 also display various neuropsychiatric symptoms. Many individuals with CTLN2 are fond of protein-rich and/or lipid-rich foods with an aversion to carbohydrate-rich foods. We herein report two cases of CTLN2 treated with living donor liver transplantation (LDLT) and provide a review of the pertinent literature. Case 1 was a 43-year-old man admitted to our hospital for repetitive episodes of consciousness disturbance. Case 2 was a 37-year-old man admitted to our hospital because of abnormal behavior associated with hyperammonemia. A definitive diagnosis of CTLN2 was accomplished by DNA analysis in both patients, who successfully underwent LDLT using liver segments from donor siblings with confirmed heterozygous gene expression. Case 2 also underwent conservative therapy with arginine and a high-fat, carbohydrate-restricted diet prior to LDLT. Postoperative recovery was uneventful and food was unrestricted in both patients. We also identified 77 cases of CTLN2 in the literature and reviewed them in terms of outcome of both liver transplantation and conservative therapy. The survival rate in patients treated by liver transplantation was 100%, whereas that in patients treated by conservative treatment showed improvement from 39.5% to 76.5% over the years. Liver transplantation is a practical treatment that fundamentally improves patient quality of life after transplantation. However, recent studies have suggested that arginine and sodium pyruvate administration combined with intensive nutritional support is also an effective therapy for CTLN2. Further development of conservative therapy may provide a safer, more affordable alternative to liver transplantation in the near future.
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Molecular genetics of citrullinemia types I and II. Clin Chim Acta 2014; 431:1-8. [DOI: 10.1016/j.cca.2014.01.032] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 01/16/2014] [Accepted: 01/18/2014] [Indexed: 12/16/2022]
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