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Kehar M, Sen Sarma M, Seetharaman J, Jimenez Rivera C, Chakraborty P. Decoding hepatorenal tyrosinemia type 1: Unraveling the impact of early detection, NTBC, and the role of liver transplantation. CANADIAN LIVER JOURNAL 2024; 7:54-63. [PMID: 38505790 PMCID: PMC10946188 DOI: 10.3138/canlivj-2023-0018] [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: 08/02/2023] [Accepted: 09/23/2023] [Indexed: 03/21/2024]
Abstract
Hepatorenal tyrosinemia type 1 (HT-1) is a rare autosomal recessive disease that results from a deficiency of fumaryl acetoacetate hydrolase (FAH), a critical enzyme in the catabolic pathway for tyrosine. This leads to the accumulation of toxic metabolites such as fumaryl and maleylacetoacetate, which can damage the liver, kidneys, and nervous system. The discovery of 2-[2-nitro-4-trifluoromethylbenzoyl]-1,3-cyclohexanedione (NTBC or nitisinone) has significantly improved the management of HT-1, particularly when initiated before the onset of symptoms. Therefore, newborn screening for HT-1 is essential for timely diagnosis and prompt treatment. The analysis of succinyl acetone (SA) in dried blood spots of newborns followed by quantification of SA in blood or urine for high-risk neonates has excellent sensitivity and specificity for the diagnosis of HT-1. NTBC combined with dietary therapy, if initiated early, can provide liver transplant (LT) free survival and reduce the risk of hepatocellular carcinoma (HCC). Patients failing medical treatment (eg, due to non-adherence), and who develop acute liver failure (ALF), have HCC or evidence of histologically proven dysplastic liver nodule(s), or experience poor quality of life secondary to severe dietary restrictions are currently indicated for LT. Children with HT-1 require frequent monitoring of liver and renal function to assess disease progression and treatment compliance. They are also at risk of long-term neurocognitive impairment, which highlights the need for neurocognitive assessment and therapy.
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Affiliation(s)
- Mohit Kehar
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children Hospital of Eastern Ontario, Ottawa, Canada
| | - Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Jayendra Seetharaman
- Division of Pediatric Gastroenterology and Hepatology, Christian Medical College, Vellore, India
| | - Carolina Jimenez Rivera
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children Hospital of Eastern Ontario, Ottawa, Canada
| | - Pranesh Chakraborty
- Department of Pediatrics, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, Ontario, Canada
- Newborn Screening Ontario, Ottawa, Ontario, Canada
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2
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Szigetvari PD, Patil S, Birkeland E, Kleppe R, Haavik J. The effects of phenylalanine and tyrosine levels on dopamine production in rat PC12 cells. Implications for treatment of phenylketonuria, tyrosinemia type 1 and comorbid neurodevelopmental disorders. Neurochem Int 2023; 171:105629. [PMID: 37865339 DOI: 10.1016/j.neuint.2023.105629] [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: 08/21/2023] [Revised: 10/11/2023] [Accepted: 10/13/2023] [Indexed: 10/23/2023]
Abstract
Phenylketonuria (PKU) is an autosomal recessive metabolic disorder caused by mutations in the phenylalanine hydroxylase (PAH) gene, resulting in phenylalanine accumulation and impaired tyrosine production. In Tyrosinemia type 1 (TYRSN1) mutations affect fumarylacetoacetate hydrolase, leading to accumulation of toxic intermediates of tyrosine catabolism. Treatment of TYRSN1 with nitisinone results in extreme tissue levels of tyrosine. Although PKU and TYRSN1 have opposite effects on tyrosine levels, both conditions have been associated with neuro-psychiatric symptoms typically present in ADHD, possibly indicating an impaired dopamine (DA) synthesis. However, concrete in vivo data on the possible molecular basis for disrupted DA production under disease mimicking conditions have been lacking. In pursuit to uncover associated molecular mechanisms, we exposed an established, DA producing cell line (PC12) to different concentrations of phenylalanine and tyrosine in culture media. We measured the effects on viability, proteomic composition, tyrosine, DA and tyrosine hydroxylase (TH) levels and TH phosphorylation. TH catalyzes the rate-limiting step in DA synthesis. High extracellular levels of phenylalanine depleted cells of intracellular tyrosine and DA. Compared to physiological levels (75 μM), either low (35 μM) or high concentrations of tyrosine (275 or 835 μM) decreased cellular DA, TH protein, and its phosphorylation levels. Using deep proteomic analysis, we identified multiple proteins, biological processes and pathways that were altered, including enzymes and transporters involved in amino acid metabolism. Using this information and published data, we developed a mathematical model to predict how extracellular levels of aromatic amino acids can affect the cellular synthesis of DA via different mechanisms. Together, these data provide new information about the normal regulation of neurotransmitter synthesis and how this may be altered in neurometabolic disorders, such as PKU and TYRSN1, with implications for the treatment of cognitive symptoms resulting from comorbid neurodevelopmental disorders.
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Affiliation(s)
| | - Sudarshan Patil
- Department of Biomedicine, University of Bergen, 5009, Bergen, Norway.
| | - Even Birkeland
- Department of Genetic Research & Bioinformatics, Norwegian Institute of Public Health, Bergen, Norway; The Proteomics Facility of the University of Bergen (PROBE), University of Bergen, Bergen, Norway
| | - Rune Kleppe
- Norwegian Centre for Maritime- and Diving Medicine, Department of Occupational Medicine, Haukeland University Hospital, 5021, Bergen, Norway.
| | - Jan Haavik
- Department of Biomedicine, University of Bergen, 5009, Bergen, Norway; Bergen Center of Brain Plasticity, Division of Psychiatry, Haukeland University Hospital, Norway.
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3
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Barone H, Elgen IB, Bliksrud YT, Vangsøy Hansen E, Skavhellen RR, Furevik MI, Haavik J. Case report: ADHD and prognosis in tyrosinemia type 1. Front Psychiatry 2023; 14:1213590. [PMID: 37533886 PMCID: PMC10392124 DOI: 10.3389/fpsyt.2023.1213590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 06/26/2023] [Indexed: 08/04/2023] Open
Abstract
Neurometabolic disorders such as tyrosinemia type 1 (TYRSN1) may interfere with brain metabolism and show symptoms of attention-deficit hyperactivity disorder (ADHD) in patients treated with the enzyme inhibitor nitisinone [2-(2-nitro-4-trifluoromethylbenzoyl)-1,3-cyclohexanedione, NTBC]. It has been reported that ADHD treatment improves treatment compliance, which is imperative for the long-term prognosis of patients with TYRSN1. In this study, we report the case of a male patient who was diagnosed with TYRSN1 at 3 months of age and was subsequently treated with NTBC, restricted protein intake, and amino acids supplementation. At 7 years of age, he was referred for neuropsychiatric assessment, diagnosed with ADHD, and treated with methylphenidate. The effects of the treatment were monitored via parental interviews, questionnaires covering ADHD symptoms, and a continuous performance test. A reduction in ADHD symptoms, particularly inattentiveness, was observed across all measures. The early identification of ADHD and the treatment of neurometabolic disorders, such as TYRSN1, may be important from a lifetime perspective as this may improve the prognosis of the medical condition as well.
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Affiliation(s)
- Helene Barone
- Regional Resource Center for Autism, ADHD and Tourette Syndrome, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Irene Bircow Elgen
- Department of Child and Adolescent Psychiatry, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | | | | | - Rita Rigmor Skavhellen
- Department of Child and Adolescent Psychiatry, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Magne Ivar Furevik
- Department of Child and Adolescent Psychiatry, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Jan Haavik
- Bergen Center of Brain Plasticity, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
- Department of Biomedicine, University of Bergen, Bergen, Norway
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4
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Davison AS, Norman BP. Alkaptonuria – Past, present and future. Adv Clin Chem 2023. [DOI: 10.1016/bs.acc.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
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5
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Lock EA. The Discovery of the Mode of Action of Nitisinone. Metabolites 2022; 12:metabo12100902. [PMID: 36295804 PMCID: PMC9609752 DOI: 10.3390/metabo12100902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/21/2022] [Accepted: 09/23/2022] [Indexed: 11/29/2022] Open
Abstract
This review briefly discusses the discovery of the mode of action of the triketone herbicide, 2-(2-nitro-4-trifluormethylbenzoyl)-1,3-cyclohexanedione and its use as a drug Nitisinone for the treatment of inborn errors of tyrosine metabolism. Nitisinone is a potent reversible tight-binding inhibitor of the enzyme 4-hydroxyphenylpyruvate dioxygenase, involved in the catabolism of the amino acid tyrosine. Nitisinone is used to treat the rare disease hereditary tyrosinaemia type 1 where the last enzyme in the breakdown of tyrosine, fumarylacetoacetase is deficient. Nitisinone is also used to treat patients with alkaptonuria where the enzyme homogentisic acid oxidase is deficient. Articles in this issue discuss metabolites of tyrosine catabolism in healthy patients and those with alkaptonuria.
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Affiliation(s)
- Edward A Lock
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Byrom Street, Liverpool L3 3AF, UK
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van Vliet K, van Ginkel WG, Jahja R, Daly A, MacDonald A, Santra S, De Laet C, Goyens PJ, Vara R, Rahman Y, Cassiman D, Eyskens F, Timmer C, Mumford N, Gissen P, Bierau J, van Hasselt PM, Wilcox G, Morris AAM, Jameson EA, de la Parra A, Arias C, Garcia MI, Cornejo V, Bosch AM, Hollak CEM, Rubio‐Gozalbo ME, Brouwers MCGJ, Hofstede FC, de Vries MC, Janssen MCH, van der Ploeg AT, Langendonk JG, Huijbregts SCJ, van Spronsen FJ. Neurocognitive outcome and mental health in children with tyrosinemia type 1 and phenylketonuria: A comparison between two genetic disorders affecting the same metabolic pathway. J Inherit Metab Dis 2022; 45:952-962. [PMID: 35722880 PMCID: PMC9540223 DOI: 10.1002/jimd.12528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/23/2022] [Accepted: 06/15/2022] [Indexed: 12/04/2022]
Abstract
Tyrosinemia type 1 (TT1) and phenylketonuria (PKU) are both inborn errors of phenylalanine-tyrosine metabolism. Neurocognitive and behavioral outcomes have always featured in PKU research but received less attention in TT1 research. This study aimed to investigate and compare neurocognitive, behavioral, and social outcomes of treated TT1 and PKU patients. We included 33 TT1 patients (mean age 11.24 years; 16 male), 31 PKU patients (mean age 10.84; 14 male), and 58 age- and gender-matched healthy controls (mean age 10.82 years; 29 male). IQ (Wechsler-subtests), executive functioning (the Behavioral Rating Inventory of Executive Functioning), mental health (the Achenbach-scales), and social functioning (the Social Skills Rating System) were assessed. Results of TT1 patients, PKU patients, and healthy controls were compared using Kruskal-Wallis tests with post-hoc Mann-Whitney U tests. TT1 patients showed a lower IQ and poorer executive functioning, mental health, and social functioning compared to healthy controls and PKU patients. PKU patients did not differ from healthy controls regarding these outcome measures. Relatively poor outcomes for TT1 patients were particularly evident for verbal IQ, BRIEF dimensions "working memory", "plan and organize" and "monitor", ASEBA dimensions "social problems" and "attention problems", and for the SSRS "assertiveness" scale (all p values <0.001). To conclude, TT1 patients showed cognitive impairments on all domains studied, and appeared to be significantly more affected than PKU patients. More attention should be paid to investigating and monitoring neurocognitive outcome in TT1 and research should focus on explaining the underlying pathophysiological mechanism.
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Affiliation(s)
- Kimber van Vliet
- Division of Metabolic DiseasesUniversity of Groningen, University Medical Center Groningen, Beatrix Children's HospitalGroningenThe Netherlands
| | - Willem G. van Ginkel
- Division of Metabolic DiseasesUniversity of Groningen, University Medical Center Groningen, Beatrix Children's HospitalGroningenThe Netherlands
| | - Rianne Jahja
- Division of Metabolic DiseasesUniversity of Groningen, University Medical Center Groningen, Beatrix Children's HospitalGroningenThe Netherlands
| | - Anne Daly
- Birmingham Children's HospitalBirminghamUK
| | | | | | - Corinne De Laet
- Hôpital Universitaire des Enfants Reine FabiolaUniversité Libre de BruxellesBrusselsBelgium
| | - Philippe J. Goyens
- Hôpital Universitaire des Enfants Reine FabiolaUniversité Libre de BruxellesBrusselsBelgium
| | | | | | - David Cassiman
- University Hospital Gasthuisberg, University of LeuvenLeuvenBelgium
| | - Francois Eyskens
- Kon. Mathilde Moeder‐ en KindcentrumUniversity Hospital of AntwerpAntwerpBelgium
| | | | - Nicky Mumford
- NIHR Great Ormond Street Hospital Biomedical Research CentreUniversity College LondonLondonUK
| | - Paul Gissen
- NIHR Great Ormond Street Hospital Biomedical Research CentreUniversity College LondonLondonUK
| | - Jörgen Bierau
- Maastricht University Medical CenterMaastrichtThe Netherlands
| | - Peter M. van Hasselt
- Wilhelmina Children's HospitalUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Gisela Wilcox
- School of Medical Sciences, Faculty of Biology Medicine & HealthUniversity of ManchesterManchesterUK
- The Mark Holland Metabolic Unit, Salford Royal Foundation NHS TrustSalfordUK
| | - Andrew A. M. Morris
- Willink Metabolic Unit, Manchester Centre for Genomic MedicineManchester University Hospitals NHS Foundation Trust, St Mary's HospitalManchesterUK
| | - Elisabeth A. Jameson
- Willink Metabolic Unit, Manchester Centre for Genomic MedicineManchester University Hospitals NHS Foundation Trust, St Mary's HospitalManchesterUK
| | - Alicia de la Parra
- Laboratory of Genetics and Metabolic Disease (LABGEM), Institute of Nutrition and Food Technology (INTA)University of ChileSantiagoChile
| | - Carolina Arias
- Laboratory of Genetics and Metabolic Disease (LABGEM), Institute of Nutrition and Food Technology (INTA)University of ChileSantiagoChile
| | - Maria I. Garcia
- Laboratory of Genetics and Metabolic Disease (LABGEM), Institute of Nutrition and Food Technology (INTA)University of ChileSantiagoChile
| | - Veronica Cornejo
- Laboratory of Genetics and Metabolic Disease (LABGEM), Institute of Nutrition and Food Technology (INTA)University of ChileSantiagoChile
| | - Annet M. Bosch
- Department of Pediatrics, Division of Metabolic Disorders, Emma Children's Hospital, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Carla E. M. Hollak
- Department of Internal MedicineDivision of Endocrinology and Metabolism, Amsterdam UMC ‐ Location AMCAmsterdamThe Netherlands
| | - M. Estela Rubio‐Gozalbo
- Departments of Pediatrics and Laboratory Genetic Metabolic DiseasesMaastricht University Medical HospitalMaastrichtThe Netherlands
| | - Martijn C. G. J. Brouwers
- Department of Internal Medicine, Division of Endocrinology and Metabolic DiseaseMaastricht University Medical CentreMaastrichtThe Netherlands
- CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtThe Netherlands
| | - Floris C. Hofstede
- Wilhelmina Children's HospitalUniversity Medical Center UtrechtUtrechtThe Netherlands
| | | | | | - Ans T. van der Ploeg
- Departments of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Janneke G. Langendonk
- Department of Internal medicine, Center for Lysosomal and Metabolic Diseases, Erasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Stephan C. J. Huijbregts
- University of Leiden, Clinical Child and Adolescent Studies: Neurodevelopmental DisordersLeidenThe Netherlands
| | - Francjan J. van Spronsen
- Division of Metabolic DiseasesUniversity of Groningen, University Medical Center Groningen, Beatrix Children's HospitalGroningenThe Netherlands
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7
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Kawabata K, Kido J, Yoshida T, Matsumoto S, Nakamura K. A case report of two siblings with hypertyrosinemia type 1 presenting with hepatic disease with different onset time and severity. Mol Genet Metab Rep 2022; 32:100892. [PMID: 35800472 PMCID: PMC9254452 DOI: 10.1016/j.ymgmr.2022.100892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/25/2022] [Accepted: 06/25/2022] [Indexed: 12/02/2022] Open
Abstract
Hereditary tyrosinemia type 1 (HT1) is an autosomal recessive disorder caused by a defect in fumarylacetoacetate hydroxylase (FAH) encoded by the FAH gene. Patients with HT1 disorder present with increased blood tyrosine, succinyl acetoacetate, and succinyl acetone levels, and develop clinical manifestations including liver failure, kidney tubular dysfunction, growth failure, rickets, pseudo-porphyric crises, and hepatocellular carcinoma. We encountered two siblings with HT1. Among the siblings, the elder brother developed acute liver failure with coagulopathy at the age of 2 months and was rescued by liver transplantation (LT) following combination therapy with continuous hemodiafiltration and plasma exchange. The younger sister was followed up from the prenatal period for signs of HT1 due to prior history of the condition in her sibling. She was initially considered a carrier of HT1 owing to the lack of overt signs of the disease and negative urine screening for succinyl acetone (SA). She was eventually diagnosed with HT1 because of liver disorder at 9 months of age, associated with a positive urine SA result. Her disease state was controlled by treatment with nitisinone (NTBC). DNA analysis of both siblings identified heterozygous status for a previously reported FAH pathogenic allele (c.782C > T) and a novel likely pathogenic variant (c.688C.G). The siblings have stable lives with no developmental delay or impaired growth. NTBC treatment is effective in preventing the progression of liver and kidney diseases. However, even in cases treated without LT, clinicians should follow up the clinical outcomes over long term, as patients may require LT when developing complications, such as hepatocellular carcinoma.
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Affiliation(s)
- Kazuo Kawabata
- Department of Pediatrics, Kumamoto University Hospital, Kumamoto, Japan
| | - Jun Kido
- Department of Pediatrics, Kumamoto University Hospital, Kumamoto, Japan
- Department of Pediatrics, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
- Corresponding author at: Department of Pediatrics, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto City, Kumamoto 860-8556, Japan.
| | - Takanobu Yoshida
- Department of Pediatrics, Kumamoto University Hospital, Kumamoto, Japan
- Department of Pediatrics, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Shirou Matsumoto
- Department of Pediatrics, Kumamoto University Hospital, Kumamoto, Japan
- Department of Pediatrics, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Kimitoshi Nakamura
- Department of Pediatrics, Kumamoto University Hospital, Kumamoto, Japan
- Department of Pediatrics, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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8
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Nicolas CT, VanLith CJ, Hickey RD, Du Z, Hillin LG, Guthman RM, Cao WJ, Haugo B, Lillegard A, Roy D, Bhagwate A, O'Brien D, Kocher JP, Kaiser RA, Russell SJ, Lillegard JB. In vivo lentiviral vector gene therapy to cure hereditary tyrosinemia type 1 and prevent development of precancerous and cancerous lesions. Nat Commun 2022; 13:5012. [PMID: 36008405 PMCID: PMC9411607 DOI: 10.1038/s41467-022-32576-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/08/2022] [Indexed: 11/23/2022] Open
Abstract
Conventional therapy for hereditary tyrosinemia type-1 (HT1) with 2-(2-nitro-4-trifluoromethylbenzoyl)−1,3-cyclohexanedione (NTBC) delays and in some cases fails to prevent disease progression to liver fibrosis, liver failure, and activation of tumorigenic pathways. Here we demonstrate cure of HT1 by direct, in vivo administration of a therapeutic lentiviral vector targeting the expression of a human fumarylacetoacetate hydrolase (FAH) transgene in the porcine model of HT1. This therapy is well tolerated and provides stable long-term expression of FAH in pigs with HT1. Genomic integration displays a benign profile, with subsequent fibrosis and tumorigenicity gene expression patterns similar to wild-type animals as compared to NTBC-treated or diseased untreated animals. Indeed, the phenotypic and genomic data following in vivo lentiviral vector administration demonstrate comparative superiority over other therapies including ex vivo cell therapy and therefore support clinical application of this approach. Hereditary tyrosinemia type 1 (HT1) is an inborn error of metabolism caused by a deficiency in fumarylacetoacetate hydrolase (FAH). Here, the authors show in an animal model that HT1 can be treated via in vivo portal vein administration of a lentiviral vector carrying the human FAH transgene.
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Affiliation(s)
- Clara T Nicolas
- Department of Surgery, Mayo Clinic, Rochester, MN, USA.,Faculty of Medicine, University of Barcelona, Barcelona, Spain.,Department of Surgery, University of Alabama Birmingham, Birmingham, AL, USA
| | | | - Raymond D Hickey
- Department of Surgery, Mayo Clinic, Rochester, MN, USA.,Department of Molecular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Zeji Du
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Lori G Hillin
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Rebekah M Guthman
- Department of Surgery, Mayo Clinic, Rochester, MN, USA.,Medical College of Wisconsin, Wausau, WI, USA
| | - William J Cao
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | - Diya Roy
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Aditya Bhagwate
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Daniel O'Brien
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Jean-Pierre Kocher
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Robert A Kaiser
- Department of Surgery, Mayo Clinic, Rochester, MN, USA.,Midwest Fetal Care Center, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
| | | | - Joseph B Lillegard
- Department of Surgery, Mayo Clinic, Rochester, MN, USA. .,Midwest Fetal Care Center, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA. .,Pediatric Surgical Associates, Minneapolis, MN, USA.
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9
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Davison AS, Hughes G, Harrold JA, Clarke P, Griffin R, Ranganath LR. Long‐term low dose nitisinone therapy in adults with alkaptonuria shows no cognitive decline or increased severity of depression. JIMD Rep 2022; 63:221-230. [PMID: 35433173 PMCID: PMC8995840 DOI: 10.1002/jmd2.12272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/10/2022] [Accepted: 01/13/2022] [Indexed: 12/13/2022] Open
Abstract
Little is documented on whether nitisinone‐induced hypertyrosinaemia alters cognitive functioning or leads to worsening depression in alkaptonuria (AKU). Wechsler Adult Intelligence Scale‐IV (WAIS‐IV) and Beck Depression Inventory‐II (BDI‐II) assessments were performed before and annually following treatment with nitisinone 2 mg daily to assess the impact on cognitive functioning and severity of depression. Serum tyrosine concentrations were also measured annually. WAIS‐IV: 63 patients (27 females/36 males: mean age[years] [±standard deviation, range] 55.7[13.7, 26–79]; 60.3[9.6, 19–75]) were included at baseline for assessment of: verbal comprehension (VC), perceptual reasoning (PR), working memory (WM), and processing speed (PS) using separate indices. Over the 6‐year period studied 43, 39, 36, 29, 26 and 15 patients had annual assessments. Using a longitudinal model (age and sex adjusted) no significant differences were observed in any of the indices over this period, apart from VC which showed a significant increase after adjustment for sex (p < 0.05). BDI‐II: 74 patients (32 females/42 males: mean age[years] [±standard deviation, range] 56.1[13.2, 26–79]; 42 males, 51.5[16.3, 19–70]) were included at baseline. Over the 7‐year period studied 48, 47, 38, 34, 32, 24 and 12 patients had annual assessments. No significant differences in BDI‐II scores were observed when compared to baseline. Hypertyrosinaemia was observed in all patients following treatment with nitisinone (p < 0.001, at all annual visits). Serum tyrosine was not correlated with WAIS‐IV sub‐test indices or BDI‐II scores pre‐ or post‐nitisinone therapy. These findings suggest that treatment with nitisinone does not affect cognitive functioning and or lead to increased severity of depression.
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Affiliation(s)
- Andrew S. Davison
- Department of Clinical Biochemistry and Metabolic Medicine, Liverpool Clinical Laboratories Royal Liverpool University Hospital Liverpool UK
| | - Gin Hughes
- Department of Psychology University of Liverpool Liverpool UK
| | | | - Pam Clarke
- Department of Psychology University of Liverpool Liverpool UK
| | - Rebecca Griffin
- Liverpool Cancer Trials Unit University of Liverpool Liverpool UK
| | - Lakshminarayan R. Ranganath
- Department of Clinical Biochemistry and Metabolic Medicine, Liverpool Clinical Laboratories Royal Liverpool University Hospital Liverpool UK
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Hereditary Tyrosinemia Type 1 in Jordan: A Retrospective Study. Int J Pediatr 2021; 2021:3327277. [PMID: 34899923 PMCID: PMC8660245 DOI: 10.1155/2021/3327277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 11/23/2022] Open
Abstract
Background Hereditary tyrosinemia type 1 (HT1) is a recessively inherited inborn error of metabolism affecting the final step of tyrosine catabolism. The accumulation of tyrosine toxic metabolites leads to progressive hepatic, renal, and neurological manifestations. Treatment of HT1 consists of tyrosine-restricted diets and nitisinone. The untreated disease progresses into life-threatening liver failure with an increased risk of hepatocellular carcinoma. Methods From April 2010 to March 2021, eighteen patients were diagnosed with HT1 in the metabolic department at Queen Rania Al Abdullah Hospital for Children in Jordan. Patients were reviewed retrospectively regarding their clinical features, laboratory data, and sociodemographic history. Results The mean age of nine boys and nine girls was 6.03 years (SD ± 3.85). The mean age for symptom onset was 5.61 months (SD ± 6.02). However, the diagnosis was belated from the onset by 10.50 months (±10.42). Nitisinone treatment was delayed from diagnosis around 12.28 months (SD ± 25.36). Most of the patients (66.7%) had acute onset of the disease. Two children (11.1%) died due to hepatic complications. Positive family history was identified in 61.1% of patients, and a similar percentage were born to parents with consanguineous marriage. The most common presentation was abdominal pain, vomiting, and fever. Hepatomegaly and abdominal distention were the most common findings. Six patients' (42.9%) first presentation was rickets. Conclusion HT1 diagnosis is usually delayed because it is not part of newborn screening and nonfamiliarity with the clinical features of the disease. Therefore, nationwide newborn screening should be expanded to include HT1.
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Yilmaz O, Daly A, Pinto A, Ashmore C, Evans S, Gupte G, Jackson R, Yabanci Ayhan N, MacDonald A. Physical Growth of Patients with Hereditary Tyrosinaemia Type I: A Single-Centre Retrospective Study. Nutrients 2021; 13:nu13093070. [PMID: 34578949 PMCID: PMC8472760 DOI: 10.3390/nu13093070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/26/2021] [Accepted: 08/30/2021] [Indexed: 12/23/2022] Open
Abstract
In a retrospective review, we aimed to assess long-term growth in 17 patients (n = 11 males) with hereditary tyrosinaemia type I (HTI). Median age at assessment was 15.6 years (5.7-26.6 years) and median age at diagnosis was 1 month (range: 0-16 months), with 35% (n = 6/17) symptomatic on presentation. From the age of 8 years, there was a noticeable change in median height, weight, and body-mass-index [BMI]-z-scores. Median height-for-age z-scores were consistently ≤ -1 (IQR -1.6, -0.5) during the first 8 years of life but increased with age. Weight-for-age z-scores ranged between -1 to 0 (IQR -1.2, 0.1) in the first 8 years; then increased to > 0.5 (IQR -0.3, 1.3) by age 16 years, and BMI-for-age z-scores ranged from 0 to 1 (IQR -0.7, 1.3) up to 8 years, and >1 (IQR -0.2, 1.9) until 16 years. The percentage of overweight and obesity was lowest in children aged < 5 years, and consistently > 40% in patients aged between 7 to 16 years. The prescribed total protein intake was associated with improved height growth (p < 0.01). Impaired growth in early life improved with age achieving normal population standards. Further studies are needed to investigate factors that influence growth outcome in HTI patients.
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Affiliation(s)
- Ozlem Yilmaz
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (O.Y.); (A.D.); (A.P.); (C.A.); (S.E.); (G.G.)
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Ankara Yildirim Beyazit University, Ankara 06760, Turkey
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Ankara University, Ankara 06290, Turkey;
| | - Anne Daly
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (O.Y.); (A.D.); (A.P.); (C.A.); (S.E.); (G.G.)
| | - Alex Pinto
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (O.Y.); (A.D.); (A.P.); (C.A.); (S.E.); (G.G.)
| | - Catherine Ashmore
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (O.Y.); (A.D.); (A.P.); (C.A.); (S.E.); (G.G.)
| | - Sharon Evans
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (O.Y.); (A.D.); (A.P.); (C.A.); (S.E.); (G.G.)
| | - Girish Gupte
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (O.Y.); (A.D.); (A.P.); (C.A.); (S.E.); (G.G.)
| | - Richard Jackson
- Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Liverpool L69 3GL, UK;
| | - Nurcan Yabanci Ayhan
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Ankara University, Ankara 06290, Turkey;
| | - Anita MacDonald
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (O.Y.); (A.D.); (A.P.); (C.A.); (S.E.); (G.G.)
- Correspondence: ; Tel.: +01213338024
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12
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Spiekerkoetter U, Couce ML, Das AM, de Laet C, Dionisi-Vici C, Lund AM, Schiff M, Spada M, Sparve E, Szamosi J, Vara R, Rudebeck M. Long-term safety and outcomes in hereditary tyrosinaemia type 1 with nitisinone treatment: a 15-year non-interventional, multicentre study. Lancet Diabetes Endocrinol 2021; 9:427-435. [PMID: 34023005 DOI: 10.1016/s2213-8587(21)00092-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/24/2021] [Accepted: 03/30/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Since the EU approval of nitisinone in 2005, prognosis for patients with hereditary tyrosinaemia type 1 has changed dramatically, with patients living with the disease now reaching adulthood for the first time in history. This study aimed to assess the long-term safety and outcomes of nitisinone treatment in patients with hereditary tyrosinaemia type 1. METHODS We did a non-interventional, non-comparative, multicentre study in 77 sites across 17 countries in Europe and collected retrospective and prospective longitudinal data in patients with hereditary tyrosinaemia type 1 who were treated with oral nitisinone during the study period (Feb 21, 2005, to Sept 30, 2019). There were no specific exclusion criteria. Patients were followed-up with an investigator at least annually for as long as they were treated, or until the end of the study. The primary endpoints, occurrence of adverse events related to hepatic, renal, ophthalmic, haematological, or cognitive or developmental function, were assessed in the complete set (all patients already receiving treatment at the index date [Feb 21, 2005] or starting treatment thereafter) and the index set (the subset of patients who had their first dose on the index date or later only). FINDINGS 315 patients were enrolled during the study period (complete set). Additionally, data from 24 patients who had liver transplantation or died during the post-marketing surveillance programme were retrieved (extended analysis set; 339 patients). Median treatment duration was 11·2 years (range 0·7-28·4); cumulative nitisinone exposure was 3172·7 patient-years. Patients who were diagnosed by neonatal screening started nitisinone treatment at median age 0·8 months versus 8·5 months in those who presented clinically. Incidences of hepatic, renal, ophthalmic, haematological, or cognitive or developmental adverse events were low. Occurrence of liver transplantation or death was more frequent the later that treatment was initiated (none of 70 patients who started treatment at age <28 days vs 35 [13%] of 268 patients who started treatment at age ≥28 days). 279 (89%) of 315 patients were assessed as having either very good or good nitisinone treatment compliance. Treatment and diet compliance declined as patients aged. Suboptimal plasma phenylalanine and tyrosine levels were observed. The majority of patients were reported to have good overall clinical condition throughout treatment; 176 (87%) of 203 during the entire study, 98% following 1 year of treatment. INTERPRETATION Long-term nitisinone treatment was well tolerated and no new safety signals were revealed. Life-limiting hepatic disease appears to have been prevented by early treatment start. Neonatal screening was the most effective way of ensuring early treatment. Standardised monitoring of blood tyrosine, phenylalanine, and nitisinone levels has potential to guide individualised therapy. FUNDING Swedish Orphan Biovitrum (Sobi).
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Affiliation(s)
- Ute Spiekerkoetter
- Department of Paediatrics and Adolescent Medicine, University Medical Centre, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Maria L Couce
- Hospital Clínico Universitario de Santiago de Compostela, Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), MetabERN, Santiago de Compostela, Spain
| | - Anibh M Das
- Department of Paediatrics, Hannover Medical School, Hannover, Germany
| | - Corinne de Laet
- Nutrition and Metabolism Unit, Department of Paediatrics, Hôpital Universitaire des Enfants Reine Fabiola, Brussels, Belgium
| | - Carlo Dionisi-Vici
- Division of Metabolism, Bambino Gesù Children's Hospital Instituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Allan M Lund
- Centre for Inherited Metabolic Diseases, Departments of Paediatrics and Clinical Genetics, Copenhagen University Hospital, Copenhagen, Denmark
| | - Manuel Schiff
- Necker Hospital, AP-HP, Reference Centre for Inborn Error of Metabolism (Filière G2M), Paediatrics Department, University of Paris, Paris, France; Inserm UMR_S1163, Institut Imagine, Paris, France
| | - Marco Spada
- Department of Paediatrics, Regina Margherita Children Hospital, University of Torino, Torino, Italy
| | - Erik Sparve
- Swedish Orphan Biovitrum (Sobi), Stockholm, Sweden
| | | | - Roshni Vara
- Department of Paediatric Inherited Metabolic Disease, Evelina London Children's Hospital, London, UK
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13
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Bärhold F, Meyer U, Neugebauer AK, Thimm EM, Lier D, Rosenbaum-Fabian S, Och U, Fekete A, Möslinger D, Rohde C, Beblo S, Hochuli M, Bogovic N, Korpel V, vom Dahl S, Mayorandan S, Fischer A, Freisinger P, Dokoupil K, Heddrich-Ellerbrok M, Jörg-Streller M, van Teeffelen-Heithoff A, Lahl J, Das AM. Hepatorenal Tyrosinaemia: Impact of a Simplified Diet on Metabolic Control and Clinical Outcome. Nutrients 2020; 13:nu13010134. [PMID: 33396520 PMCID: PMC7824011 DOI: 10.3390/nu13010134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 12/16/2020] [Accepted: 12/30/2020] [Indexed: 12/17/2022] Open
Abstract
Background: Tyrosinaemia type 1 is a rare inherited metabolic disease caused by an enzyme defect in the tyrosine degradation pathway. It is treated using nitisinone and a low-protein diet. In a workshop in 2013, a group of nutritional specialists from Germany, Switzerland and Austria agreed to advocate a simplified low-protein diet and to allow more natural protein intake in patients with tyrosinaemia type 1. This retrospective study evaluates the recommendations made at different treatment centers and their impact on clinical symptoms and metabolic control. Methods: For this multicenter study, questionnaires were sent to nine participating treatment centers to collect data on the general therapeutic approach and data of 47 individual patients treated by those centers. Results: Dietary simplification allocating food to 3 categories led to increased tyrosine and phenylalanine blood concentrations without weighing food. Phenylalanine levels were significantly higher in comparison to a strict dietary regimen whereas tyrosine levels in plasma did not change. Non-inferiority was shown for the simplification and liberalization of the diet. Compliance with dietary recommendations was higher using the simplified diet in comparison to the stricter approach. Age correlates negatively with compliance. Conclusions: Simplification of the diet with increased natural protein intake based on three categories of food may be implemented in the diet of patients with tyrosinaemia type 1 without significantly altering metabolic control. Patient compliance is strongly influencing tyrosine blood concentrations. A subsequent prospective study with a larger sample size is necessary to get a better insight into the effect of dietary recommendations on metabolic control.
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Affiliation(s)
- Friederike Bärhold
- Department of Paediatrics, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany; (F.B.); (U.M.); (S.M.)
| | - Uta Meyer
- Department of Paediatrics, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany; (F.B.); (U.M.); (S.M.)
| | - Anne-Kathrin Neugebauer
- Klinik für Allgemeine Pädiatrie, Universitätsklinikum Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany; (A.-K.N.); (E.M.T.)
| | - Eva Maria Thimm
- Klinik für Allgemeine Pädiatrie, Universitätsklinikum Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany; (A.-K.N.); (E.M.T.)
| | - Dinah Lier
- Klinik für Kinder- und Jugendmedizin, Stoffwechselzentrum, Klinikum am Steinenberg, Steinenbergstraße 31, 72764 Reutlingen, Germany; (D.L.); (A.F.); (P.F.)
| | - Stefanie Rosenbaum-Fabian
- Zentrum für Kinder- u. Jugendmedizin, Universitätsklinikum Freiburg, Mathildenstraße 1, 79106 Freiburg, Germany;
| | - Ulrike Och
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany; (U.O.); (A.v.T.-H.)
| | - Anna Fekete
- Kinder- und Jugendheilkunde, AKH Universitätsklinikum Wien, Währinger Gürtel 18-20, 1090 Wien, Austria; (A.F.); (D.M.)
| | - Dorothea Möslinger
- Kinder- und Jugendheilkunde, AKH Universitätsklinikum Wien, Währinger Gürtel 18-20, 1090 Wien, Austria; (A.F.); (D.M.)
| | - Carmen Rohde
- Universitätsklinik für Kinder und Jugendliche, Universitätsklinikum Leipzig, Liebigstraße 20 a, 04103 Leipzig, Germany; (C.R.); (S.B.)
| | - Skadi Beblo
- Universitätsklinik für Kinder und Jugendliche, Universitätsklinikum Leipzig, Liebigstraße 20 a, 04103 Leipzig, Germany; (C.R.); (S.B.)
| | - Michel Hochuli
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Rämistraße 100, 8091 Zürich, Switzerland;
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism Inselspital Bern, University Hospital and University of Bern, Freiburgstrasse 15, 3010 Bern, Switzerland
| | - Nina Bogovic
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany; (N.B.); (V.K.); (S.v.D.)
| | - Vanessa Korpel
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany; (N.B.); (V.K.); (S.v.D.)
| | - Stephan vom Dahl
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany; (N.B.); (V.K.); (S.v.D.)
| | - Sebene Mayorandan
- Department of Paediatrics, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany; (F.B.); (U.M.); (S.M.)
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany; (U.O.); (A.v.T.-H.)
| | - Aleksandra Fischer
- Klinik für Kinder- und Jugendmedizin, Stoffwechselzentrum, Klinikum am Steinenberg, Steinenbergstraße 31, 72764 Reutlingen, Germany; (D.L.); (A.F.); (P.F.)
| | - Peter Freisinger
- Klinik für Kinder- und Jugendmedizin, Stoffwechselzentrum, Klinikum am Steinenberg, Steinenbergstraße 31, 72764 Reutlingen, Germany; (D.L.); (A.F.); (P.F.)
| | - Katharina Dokoupil
- Dr. von Haunersches Kinderspital, Lindwurmstraße 4, 80337 München, Germany;
| | - Margret Heddrich-Ellerbrok
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Hamburg Eppendorf, Martinistraße 52, 20246 Hamburg, Germany;
| | - Monika Jörg-Streller
- Department für Kinder- und Jugendheilkunde, Medizinische Universität Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria;
| | - Agnes van Teeffelen-Heithoff
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany; (U.O.); (A.v.T.-H.)
| | - Janina Lahl
- Nutricia GmbH, Metabolics Expert Centre, Am Hauptbahnhof 18, 60329 Frankfurt, Germany;
| | - Anibh Martin Das
- Department of Paediatrics, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany; (F.B.); (U.M.); (S.M.)
- Correspondence: ; Tel.: +49-511-532-3220; Fax: +49-511-532-18516
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Abstract
Background Introduction of nitisinone and newborn screening (NBS) have transformed the treatment of type 1 tyrosinemia, but the effects of these changes on the long-term outcomes remain obscure. Also, the predictors for later complications, the significance of drug levels and the normalization of laboratory and imaging findings are poorly known. We investigated these issues in a nationwide study. Results Type 1 tyrosinemia was diagnosed in 22 children in 1978–2019 in Finland. Incidence was 1/90,102, with a significant enrichment in South Ostrobothnia (1/9990). Median age at diagnosis was 5 (range 0.5–36) months, 55% were girls and 13 had homozygotic Trp262X mutation. Four patients were detected through screening and 18 clinically, their main findings being liver failure (50% vs. 100%, respectively, p = 0.026), ascites (0% vs. 53%, p = 0.104), renal tubulopathy (0% vs. 65%, p = 0.035), rickets (25% vs. 65%, p = 0.272), growth failure (0% vs. 66%, p = 0.029), thrombocytopenia (25% vs. 88%, p = 0.028) and anaemia (0% vs. 47%, p = 0.131). One patient was treated with diet, seven with transplantation and 14 with nitisinone. Three late-diagnosed (6–33 months) nitisinone treated patients needed transplantation later. Kidney dysfunction (86% vs. 7%, p = 0.001), hypertension (57% vs. 7%, p = 0.025) and osteopenia/osteoporosis (71% vs. 14%, p = 0.017) were more frequent in transplanted than nitisinone-treated patients. Blood/serum alpha-fetoprotein decreased rapidly on nitisinone in all but one patient, who later developed intrahepatic hepatocellular carcinoma. Liver values normalized in 31 months and other laboratory values except thrombocytopenia within 18 months. Imaging findings normalized in 3–56 months excluding five patients with liver or splenic abnormalities. Low mean nitisinone concentration was associated with higher risk of severe complications (r = 0.758, p = 0.003) despite undetectable urine succinylacetone. Conclusions Prognosis of type 1 tyrosinemia has improved in the era of nitisinone, and NBS seems to provide further benefits. Nevertheless, the long-term risk for complications remains, particularly in the case of late diagnosis and/or insufficient nitisinone levels.
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Thompson WS, Mondal G, Vanlith CJ, Kaiser RA, Lillegard JB. The future of gene-targeted therapy for hereditary tyrosinemia type 1 as a lead indication among the inborn errors of metabolism. Expert Opin Orphan Drugs 2020; 8:245-256. [PMID: 33224636 PMCID: PMC7676758 DOI: 10.1080/21678707.2020.1791082] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction Inborn errors of metabolism (IEMs) often result from single-gene mutations and collectively cause liver dysfunction in neonates leading to chronic liver and systemic disease. Current treatments for many IEMs are limited to maintenance therapies that may still require orthotropic liver transplantation. Gene therapies offer a potentially superior approach by correcting or replacing defective genes with functional isoforms; however, they face unique challenges from complexities presented by individual diseases and their diverse etiology, presentation, and pathophysiology. Furthermore, immune responses, off-target gene disruption, and tumorigenesis are major concerns that need to be addressed before clinical application of gene therapy. Areas covered The current treatments for IEMs are reviewed as well as the advances in, and barriers to, gene therapy for IEMs. Attention is then given to ex vivo and in vivo gene therapy approaches for hereditary tyrosinemia type 1 (HT1). Of all IEMs, HT1 is particularly amenable to gene therapy because of a selective growth advantage conferred to corrected cells, thereby lowering the initial transduction threshold for phenotypic relevance. Expert opinion It is proposed that not only is HT1 a safe indication for gene therapy, its unique characteristics position it to be an ideal IEM to develop for clinical investigation.
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Affiliation(s)
| | - Gourish Mondal
- Department of Surgery, Research Scientist, Mayo Clinic, Rochester, MN, USA
| | | | - Robert A Kaiser
- Department of Surgery, Research Scientist, Mayo Clinic, Rochester, MN, USA.,Midwest Fetal Care Center, Childrens Hospital of Minnesota, MN, USA
| | - Joseph B Lillegard
- Midwest Fetal Care Center, Childrens Hospital of Minnesota, MN, USA.,Assistant Professor of Surgery, Mayo Clinic, Rochester, MN, USA
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Yilmaz O, Daly A, Pinto A, Ashmore C, Evans S, Gupte G, Santra S, Preece MA, Mckiernan P, Kitchen S, Yabanci Ayhan N, MacDonald A. Natural Protein Tolerance and Metabolic Control in Patients with Hereditary Tyrosinaemia Type 1. Nutrients 2020; 12:E1148. [PMID: 32325917 PMCID: PMC7230348 DOI: 10.3390/nu12041148] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/15/2020] [Accepted: 04/15/2020] [Indexed: 12/23/2022] Open
Abstract
In a longitudinal retrospective study, we aimed to assess natural protein (NP) tolerance and metabolic control in a cohort of 20 Hereditary Tyrosinaemia type I (HTI) patients. Their median age was 12 years ([3.2-17.7 years], n = 11 female, n = 8 Caucasian, n = 8 Asian origin, n = 2 Arabic and n = 2 Indian). All were on nitisinone (NTBC) with a median dose of 0.7 g/kg/day (range 0.4-1.5 g/kg/day) and were prescribed a tyrosine (Tyr)/phenylalanine (Phe)-restricted diet supplemented with Tyr/Phe-free L-amino acids. Data were collected on clinical signs at presentation, medical history, annual dietary prescriptions, and blood Phe and Tyr levels from diagnosis until transition to the adult service (aged 16-18 years) or liver transplantation (if it preceded transition). The median age of diagnosis was 2 months (range: 0 to 24 months), with n = 1 diagnosed by newborn screening, n = 3 following phenylketonuria (PKU) screening and n = 7 by sibling screening. Five patients were transplanted (median age 6.3 years), and one died due to liver cancer. The median follow-up was 10 years (3-16 years), and daily prescribed NP intake increased from a median of 5 to 24 g/day. Lifetime median blood Tyr (370 µmol/L, range 280-420 µmol/L) and Phe (50 µmol/L, 45-70 µmol/L) were maintained within the target recommended ranges. This cohort of HTI patients were able to increase the daily NP intake with age while maintaining good metabolic control. Extra NP may improve lifelong adherence to the diet.
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Affiliation(s)
- Ozlem Yilmaz
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (O.Y.); (A.D.); (A.P.); (C.A.); (S.E.); (G.G.); (S.S.); (M.A.P.); (S.K.)
- Department of Nutrition and Dietetics, Ankara Yildirim Beyazit University, 06760 Ankara, Turkey
| | - Anne Daly
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (O.Y.); (A.D.); (A.P.); (C.A.); (S.E.); (G.G.); (S.S.); (M.A.P.); (S.K.)
| | - Alex Pinto
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (O.Y.); (A.D.); (A.P.); (C.A.); (S.E.); (G.G.); (S.S.); (M.A.P.); (S.K.)
| | - Catherine Ashmore
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (O.Y.); (A.D.); (A.P.); (C.A.); (S.E.); (G.G.); (S.S.); (M.A.P.); (S.K.)
| | - Sharon Evans
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (O.Y.); (A.D.); (A.P.); (C.A.); (S.E.); (G.G.); (S.S.); (M.A.P.); (S.K.)
| | - Girish Gupte
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (O.Y.); (A.D.); (A.P.); (C.A.); (S.E.); (G.G.); (S.S.); (M.A.P.); (S.K.)
| | - Saikat Santra
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (O.Y.); (A.D.); (A.P.); (C.A.); (S.E.); (G.G.); (S.S.); (M.A.P.); (S.K.)
| | - Mary Anne Preece
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (O.Y.); (A.D.); (A.P.); (C.A.); (S.E.); (G.G.); (S.S.); (M.A.P.); (S.K.)
| | - Patrick Mckiernan
- Gastroenterology/ Hepatic/Nutrition, UPMC, Children’s Hospital of Pittsburg, Pittsburg, PA 15224, USA;
| | - Steve Kitchen
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (O.Y.); (A.D.); (A.P.); (C.A.); (S.E.); (G.G.); (S.S.); (M.A.P.); (S.K.)
| | | | - Anita MacDonald
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (O.Y.); (A.D.); (A.P.); (C.A.); (S.E.); (G.G.); (S.S.); (M.A.P.); (S.K.)
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Combined 3D-quantitative structure-activity relationships and topomer technology-based molecular design of human 4-hydroxyphenylpyruvate dioxygenase inhibitors. Future Med Chem 2020; 12:795-811. [PMID: 32223563 DOI: 10.4155/fmc-2019-0349] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Aim: 4-Hydroxyphenylpyruvate dioxygenase (HPPD) has attracted increasing attention as an important target against tyrosinemia type I. This paper aimed to explore the structure-activity relationship of HPPD inhibitors with pyrazole scaffolds and to design novel HPPD inhibitors. Methodology & results: The best 3D-quantitative structure-activity relationships model was established by two different strategies based on 40 pyrazole scaffold-based analogs. Screening of molecular fragments by topomer technology, combined with molecular docking, 14 structures were identified for potential human HPPD inhibitory activity. Molecular dynamics results demonstrated that all the compounds obtained bound to the enzyme and possessed a satisfactory binding free energy. Conclusion: The quantitative structure-activity relationship of HPPD inhibitors of pyrazole scaffolds was clarified and 14 original structures with potential human HPPD inhibitory activity were obtained.
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Barone H, Bliksrud YT, Elgen IB, Szigetvari PD, Kleppe R, Ghorbani S, Hansen EV, Haavik J. Tyrosinemia Type 1 and symptoms of ADHD: Biochemical mechanisms and implications for treatment and prognosis. Am J Med Genet B Neuropsychiatr Genet 2020; 183:95-105. [PMID: 31633311 DOI: 10.1002/ajmg.b.32764] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 08/25/2019] [Accepted: 09/17/2019] [Indexed: 12/20/2022]
Abstract
Hereditary tyrosinemia Type 1 (HT-1) is a rare metabolic disease where the enzyme catalyzing the final step of tyrosine breakdown is defect, leading to accumulation of toxic metabolites. Nitisinone inhibits the degradation of tyrosine and thereby the production of harmful metabolites, however, the concentration of tyrosine also increases. We investigated the relationship between plasma tyrosine concentrations and cognitive functions and how tyrosine levels affected enzyme activities of human tyrosine hydroxylase (TH) and tryptophan hydroxylase 2 (TPH2). Eight Norwegian children between 6 and 18 years with HT-1 were assessed using questionnaires measuring Attention Deficit Hyperactivity Disorder (ADHD)-symptoms and executive functioning. Recent and past levels of tyrosine were measured and the enzyme activities of TH and TPH2 were studied at conditions replicating normal and pathological tyrosine concentrations. We observed a significant positive correlation between mean tyrosine levels and inattention symptoms. While TH exhibited prominent substrate inhibition kinetics, TPH2 activity also decreased at elevated tyrosine levels. Inhibition of both enzymes may impair syntheses of dopamine, noradrenaline, and serotonin in brain tissue. Inattention in treated HT-1 patients may be related to decreased production of these monoamines. Our results support recommendations of strict guidelines on plasma tyrosine levels in HT-1. ADHD-related deficits, particularly inattention, should be monitored in HT-1 patients to determine whether intervention is necessary.
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Affiliation(s)
- Helene Barone
- Department of Child and Adolescent Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Yngve T Bliksrud
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Irene B Elgen
- Department of Child and Adolescent Psychiatry, Haukeland University Hospital, Bergen, Norway
| | | | - Rune Kleppe
- Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Sadaf Ghorbani
- Department of Biomedicine, University of Bergen, Bergen, Norway
| | - Eirik V Hansen
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Jan Haavik
- Department of Biomedicine, University of Bergen, Bergen, Norway.,Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
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19
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Exploring the therapeutic potential of modern and ancestral phenylalanine/tyrosine ammonia-lyases as supplementary treatment of hereditary tyrosinemia. Sci Rep 2020; 10:1315. [PMID: 31992763 PMCID: PMC6987202 DOI: 10.1038/s41598-020-57913-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 01/07/2020] [Indexed: 12/01/2022] Open
Abstract
Phenylalanine/tyrosine ammonia-lyases (PAL/TALs) have been approved by the FDA for treatment of phenylketonuria and may harbour potential for complementary treatment of hereditary tyrosinemia Type I. Herein, we explore ancestral sequence reconstruction as an enzyme engineering tool to enhance the therapeutic potential of PAL/TALs. We reconstructed putative ancestors from fungi and compared their catalytic activity and stability to two modern fungal PAL/TALs. Surprisingly, most putative ancestors could be expressed as functional tetramers in Escherichia coli and thus retained their ability to oligomerize. All ancestral enzymes displayed increased thermostability compared to both modern enzymes, however, the increase in thermostability was accompanied by a loss in catalytic turnover. One reconstructed ancestral enzyme in particular could be interesting for further drug development, as its ratio of specific activities is more favourable towards tyrosine and it is more thermostable than both modern enzymes. Moreover, long-term stability assessment showed that this variant retained substantially more activity after prolonged incubation at 25 °C and 37 °C, as well as an increased resistance to incubation at 60 °C. Both of these factors are indicative of an extended shelf-life of biopharmaceuticals. We believe that ancestral sequence reconstruction has potential for enhancing the properties of enzyme therapeutics, especially with respect to stability. This work further illustrates that resurrection of putative ancestral oligomeric proteins is feasible and provides insight into the extent of conservation of a functional oligomerization surface area from ancestor to modern enzyme.
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20
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van Vliet K, van Ginkel WG, Jahja R, Daly A, MacDonald A, De Laet C, Vara R, Rahman Y, Cassiman D, Eyskens F, Timmer C, Mumford N, Bierau J, van Hasselt PM, Gissen P, Goyens PJ, McKiernan PJ, Wilcox G, Morris AAM, Jameson EA, Huijbregts SCJ, van Spronsen FJ. Emotional and behavioral problems, quality of life and metabolic control in NTBC-treated Tyrosinemia type 1 patients. Orphanet J Rare Dis 2019; 14:285. [PMID: 31801588 PMCID: PMC6894144 DOI: 10.1186/s13023-019-1259-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 11/22/2019] [Indexed: 02/06/2023] Open
Abstract
Abstract Background Treatment with 2-(2-nitro-4-trifluoromethylbenzoyl)-1,3-cyclohexanedione (NTBC) and dietary phenylalanine and tyrosine restriction improves physical health and life expectancy in Tyrosinemia type 1 (TT1). However, neurocognitive outcome is suboptimal. This study aimed to investigate behavior problems and health-related quality of life (HR-QoL) in NTBC-dietary-treated TT1 and to relate this to phenylalanine and tyrosine concentrations. Results Thirty-one TT1 patients (19 males; mean age 13.9 ± 5.3 years) were included in this study. Emotional and behavioral problems, as measured by the Achenbach System of Empirically Based Assessment, were present in almost all domains. Attention and thought problems were particularly evident. HR-QoL was assessed by the TNO AZL Children’s and Adults QoL questionnaires. Poorer HR-QoL as compared to reference populations was observed for the domains: independent daily functioning, cognitive functioning and school performance, social contacts, motor functioning, and vitality. Both internalizing and externalizing behavior problems were associated with low phenylalanine (and associated lower tyrosine) concentrations during the first year of life. In contrast, high tyrosine (and associated higher phenylalanine) concentrations during life and specifically the last year before testing were associated with more internalizing behavior and/or HR-QoL problems. Conclusions TT1 patients showed several behavior problems and a lower HR-QoL. Associations with metabolic control differed for different age periods. This suggests the need for continuous fine-tuning and monitoring of dietary treatment to keep phenylalanine and tyrosine concentrations within target ranges in NTBC-treated TT1 patients.
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Affiliation(s)
- Kimber van Vliet
- Beatrix Children's Hospital, Groningen, Division of Metabolic Diseases, University of Groningen, University Medical Center Groningen, CA33, PO box 30.001, 9700 RB, Groningen, Netherlands
| | - Willem G van Ginkel
- Beatrix Children's Hospital, Groningen, Division of Metabolic Diseases, University of Groningen, University Medical Center Groningen, CA33, PO box 30.001, 9700 RB, Groningen, Netherlands
| | - Rianne Jahja
- Beatrix Children's Hospital, Groningen, Division of Metabolic Diseases, University of Groningen, University Medical Center Groningen, CA33, PO box 30.001, 9700 RB, Groningen, Netherlands
| | - Anne Daly
- Birmingham Children's Hospital, Birmingham, UK
| | | | - Corinne De Laet
- Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Roshni Vara
- Evelina London Children's Hospital, London, UK
| | | | - David Cassiman
- University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
| | - Francois Eyskens
- Kon. Mathilde Moeder- en Kindcentrum, University Hospital of Antwerp, Antwerp, Belgium
| | | | - Nicky Mumford
- The NIHR Great Ormond Street Hospital Biomedical Research Centre (BRC ), London, UK
| | - Jörgen Bierau
- Maastricht University Medical Center, Maastricht, Netherlands
| | - Peter M van Hasselt
- Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Utrecht, Netherlands
| | - Paul Gissen
- The NIHR Great Ormond Street Hospital Biomedical Research Centre (BRC ), London, UK
| | - Philippe J Goyens
- Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Gisela Wilcox
- School of Medical Sciences, Faculty of Biology Medicine & Health, University of Manchester, Manchester, UK.,The Mark Holland Metabolic Unit, Salford Royal Foundation NHS Trust, Greater Manchester, M6 8HD, Salford, UK
| | - Andrew A M Morris
- Willink Metabolic Unit, Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, St Mary's Hospital, Manchester, UK
| | - Elisabeth A Jameson
- Willink Metabolic Unit, Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, St Mary's Hospital, Manchester, UK
| | - Stephan C J Huijbregts
- University of Leiden, Clinical Child and Adolescent Studies: Neurodevelopmental Disorders, Leiden, Netherlands
| | - Francjan J van Spronsen
- Beatrix Children's Hospital, Groningen, Division of Metabolic Diseases, University of Groningen, University Medical Center Groningen, CA33, PO box 30.001, 9700 RB, Groningen, Netherlands.
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21
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Blood and Brain Biochemistry and Behaviour in NTBC and Dietary Treated Tyrosinemia Type 1 Mice. Nutrients 2019; 11:nu11102486. [PMID: 31623189 PMCID: PMC6836052 DOI: 10.3390/nu11102486] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 10/11/2019] [Accepted: 10/14/2019] [Indexed: 02/05/2023] Open
Abstract
Tyrosinemia type 1 (TT1) is a rare metabolic disease caused by a defect in the tyrosine degradation pathway. Neurocognitive deficiencies have been described in TT1 patients, that have, among others, been related to changes in plasma large neutral amino acids (LNAA) that could result in changes in brain LNAA and neurotransmitter concentrations. Therefore, this project aimed to investigate plasma and brain LNAA, brain neurotransmitter concentrations and behavior in C57 Bl/6 fumarylacetoacetate hydrolase deficient (FAH−/−) mice treated with 2-(2-nitro-4-trifluoromethylbenoyl)-1,3-cyclohexanedione (NTBC) and/or diet and wild-type mice. Plasma and brain tyrosine concentrations were clearly increased in all NTBC treated animals, even with diet (p < 0.001). Plasma and brain phenylalanine concentrations tended to be lower in all FAH−/− mice. Other brain LNAA, were often slightly lower in NTBC treated FAH−/− mice. Brain neurotransmitter concentrations were usually within a normal range, although serotonin was negatively correlated with brain tyrosine concentrations (p < 0.001). No clear behavioral differences between the different groups of mice could be found. To conclude, this is the first study measuring plasma and brain biochemistry in FAH−/− mice. Clear changes in plasma and brain LNAA have been shown. Further research should be done to relate the biochemical changes to neurocognitive impairments in TT1 patients.
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22
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Davison AS, Hughes AT, Milan AM, Sireau N, Gallagher JA, Ranganath LR. Alkaptonuria – Many questions answered, further challenges beckon. Ann Clin Biochem 2019; 57:106-120. [DOI: 10.1177/0004563219879957] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Alkaptonuria is an iconic rare inherited inborn error of metabolism affecting the tyrosine metabolic pathway, resulting in the accumulation of homogentisic acid in the circulation, and significant excretion in urine. Dating as far back as 1500 BC in the Egyptian mummy Harwa, homogentisic acid was shown to be central to the pathophysiology of alkaptonuria through its deposition in collagenous tissues in a process termed ochronosis. Clinical manifestations occurring as a consequence of this are typically observed from the third decade of life, are lifelong and significantly affect the quality of life. In large supportive and palliative treatment measures are available to patients, including analgesia, physiotherapy and joint replacement. Studying the natural history of alkaptonuria, in a murine model and human subjects, has provided key insights into the biochemical and molecular mechanisms underlying the pathophysiology associated with the disease, and has enabled a better understanding of the common disease osteoarthritis. In the last decade, a major focus has been on an unlicensed disease-modifying therapy called nitisinone. This has been shown to be highly efficacious in reducing homogentisic acid, and it is hoped this will halt ochronosis, thus limiting the clinical complications associated with the disease. A well-documented metabolic consequence of nitisinone therapy is hypertyrosinaemia, the clinical implications of which are uncertain. Recent metabolomic studies have helped understand the wider metabolic consequences of nitisinone therapy.
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Affiliation(s)
- AS Davison
- Department of Clinical Biochemistry and Metabolic Medicine, Liverpool Clinical Laboratories, Royal Liverpool University Hospitals Trust, Liverpool, UK
- Musculoskeletal Biology I, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool Health Partners, Liverpool, UK
| | - AT Hughes
- Department of Clinical Biochemistry and Metabolic Medicine, Liverpool Clinical Laboratories, Royal Liverpool University Hospitals Trust, Liverpool, UK
- Musculoskeletal Biology I, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool Health Partners, Liverpool, UK
| | - AM Milan
- Department of Clinical Biochemistry and Metabolic Medicine, Liverpool Clinical Laboratories, Royal Liverpool University Hospitals Trust, Liverpool, UK
- Musculoskeletal Biology I, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool Health Partners, Liverpool, UK
| | | | - JA Gallagher
- Musculoskeletal Biology I, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool Health Partners, Liverpool, UK
| | - LR Ranganath
- Department of Clinical Biochemistry and Metabolic Medicine, Liverpool Clinical Laboratories, Royal Liverpool University Hospitals Trust, Liverpool, UK
- Musculoskeletal Biology I, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool Health Partners, Liverpool, UK
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23
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Couce ML, Sánchez-Pintos P, Aldámiz-Echevarría L, Vitoria I, Navas V, Martín-Hernández E, García-Volpe C, Pintos G, Peña-Quintana L, Hernández T, Gil D, Sánchez-Valverde F, Bueno M, Roca I, López-Ruzafa E, Díaz-Fernández C. Evolution of tyrosinemia type 1 disease in patients treated with nitisinone in Spain. Medicine (Baltimore) 2019; 98:e17303. [PMID: 31574857 PMCID: PMC6775438 DOI: 10.1097/md.0000000000017303] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Treatment with nitisinone (NTBC) has brought about a drastic improvement in the treatment and prognosis of hereditary tyrosinemia type I (HT1). We conducted a retrospective observational multicentric study in Spanish HT1 patients treated with NTBC to assess clinical and biochemical long-term evolution.We evaluated 52 patients, 7 adults and 45 children, treated with NTBC considering: age at diagnosis, diagnosis by clinical symptoms, or by newborn screening (NBS); phenotype (acute/subacute/chronic), mutational analysis; symptoms at diagnosis and clinical course; biochemical markers; doses of NTBC; treatment adherence; anthropometric evolution; and neurocognitive outcome.The average follow-up period was 6.1 ± 4.9 and 10.6 ± 5.4 years in patients with early and late diagnosis respectively. All patients received NTBC from diagnosis with an average dose of 0.82 mg/kg/d. All NBS-patients (n = 8) were asymptomatic at diagnosis except 1 case with acute liver failure, and all remain free of liver and renal disease in follow-up. Liver and renal affectation was markedly more frequent at diagnosis in patients with late diagnosis (P < .001 and .03, respectively), with ulterior positive hepatic and renal course in 86.4% and 93.2% of no-NBS patients, although 1 patient with good metabolic control developed hepatocarcinoma.Despite a satisfactory global nutritional evolution, 46.1% of patients showed overweight/obesity. Interestingly lower body mass index was observed in patients with good dietary adherence (20.40 ± 4.43 vs 24.30 ± 6.10; P = .08) and those with good pharmacological adherence (21.19 ± 4.68 vs 28.58 ± 213.79).intellectual quotient was ≥85 in all NBS- and 68.75% of late diagnosis cases evaluated, 15% of which need pedagogical support, and 6.8% (3/44) showed school failure.Among the 12 variants identified in fumarylacetoacetate hydrolase gene, 1 of them novel (H63D), the most prevalent in Spanish population is c.554-1 G>T.After NTBC treatment a reduction in tyrosine and alpha-fetoprotein levels was observed in all the study groups, significant for alpha-fetoprotein in no NBS-group (P = .03), especially in subacute/chronic forms (P = .018).This series confirms that NTBC treatment had clearly improved the prognosis and quality of life of HT1 patients, but it also shows frequent cognitive dysfunctions and learning difficulties in medium-term follow-up, and, in a novel way, a high percentage of overweight/obesity.
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Affiliation(s)
- María Luz Couce
- Unit of Diagnosis and Treatment of Congenital Metabolic Diseases, S. Neonatology, Department of Pediatrics, Clínico Universitario de Santiago de Compostela, CIBERER, Health Research Institute of Santiago de Compostela (IDIS)
| | - Paula Sánchez-Pintos
- Unit of Diagnosis and Treatment of Congenital Metabolic Diseases, S. Neonatology, Department of Pediatrics, Clínico Universitario de Santiago de Compostela, CIBERER, Health Research Institute of Santiago de Compostela (IDIS)
| | - Luís Aldámiz-Echevarría
- Unit of Metabolism, Department of Pediatrics, Hospital de Cruces, Group of Metabolism, Biocruces Health Research Institute, CIBERER
| | | | - Victor Navas
- Pediatric Gastroenterology and Nutrition Unit Hospital Carlos Haya, Málaga
| | | | - Camila García-Volpe
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, H. San Joan de Deu, Barcelona
| | | | - Luis Peña-Quintana
- Gastroenterology and Nutrition Unit Complejo Hospitalario Universitario Insular-Materno Infantil, CIBEROBN, Las Palmas de Gran Canaria University, Las Palmas
| | | | - David Gil
- Pediatric Gastroenterology, Hepatology and Nutrition Unit Hospital Virgen da Arrixaca, Murcia
| | | | - María Bueno
- Metabolic Congenital Diseases Unit, Hospital Virgen del Rocío, Sevilla
| | - Iria Roca
- Unit of Diagnosis and Treatment of Congenital Metabolic Diseases, S. Neonatology, Department of Pediatrics, Clínico Universitario de Santiago de Compostela, CIBERER, Health Research Institute of Santiago de Compostela (IDIS)
| | | | - Carmen Díaz-Fernández
- Unit of Hepatology and Infantile Hepatic Transplantation, Hospital Universitario La Paz, Madrid, Spain
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24
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van Vliet K, Rodenburg IL, van Ginkel WG, Lubout CMA, Wolffenbuttel BHR, van der Klauw MM, Heiner-Fokkema MR, van Spronsen FJ. Biomarkers of Micronutrients in Regular Follow-Up for Tyrosinemia Type 1 and Phenylketonuria Patients. Nutrients 2019; 11:E2011. [PMID: 31461828 PMCID: PMC6769775 DOI: 10.3390/nu11092011] [Citation(s) in RCA: 4] [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: 07/17/2019] [Revised: 08/16/2019] [Accepted: 08/21/2019] [Indexed: 12/26/2022] Open
Abstract
Phenylketonuria (PKU) is treated with dietary restrictions and sometimes tetrahydrobiopterin (BH4). PKU patients are at risk for developing micronutrient deficiencies, such as vitamin B12 and folic acid, likely due to their diet. Tyrosinemia type 1 (TT1) is similar to PKU in both pathogenesis and treatment. TT1 patients follow a similar diet, but nutritional deficiencies have not been investigated yet. In this retrospective study, biomarkers of micronutrients in TT1 and PKU patients were investigated and outcomes were correlated to dietary intake and anthropometric measurements from regular follow-up measurements from patients attending the outpatient clinic. Data was analyzed using Kruskal-Wallis, Fisher's exact and Spearman correlation tests. Furthermore, descriptive data were used. Overall, similar results for TT1 and PKU patients (with and without BH4) were observed. In all groups high vitamin B12 concentrations were seen rather than B12 deficiencies. Furthermore, all groups showed biochemical evidence of vitamin D deficiency. This study shows that micronutrients in TT1 and PKU patients are similar and often within the normal ranges and that vitamin D concentrations could be optimized.
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Affiliation(s)
- Kimber van Vliet
- Division of Metabolic Diseases, Groningen, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Iris L Rodenburg
- Division of Metabolic Diseases, Groningen, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Willem G van Ginkel
- Division of Metabolic Diseases, Groningen, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Charlotte M A Lubout
- Division of Metabolic Diseases, Groningen, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Bruce H R Wolffenbuttel
- Department of Endocrinology, Groningen, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Melanie M van der Klauw
- Department of Endocrinology, Groningen, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - M Rebecca Heiner-Fokkema
- Laboratory of Metabolic Diseases, Groningen, Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Francjan J van Spronsen
- Division of Metabolic Diseases, Groningen, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands.
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25
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Norman BP, Davison AS, Ross GA, Milan AM, Hughes AT, Sutherland H, Jarvis JC, Roberts NB, Gallagher JA, Ranganath LR. A Comprehensive LC-QTOF-MS Metabolic Phenotyping Strategy: Application to Alkaptonuria. Clin Chem 2019; 65:530-539. [DOI: 10.1373/clinchem.2018.295345] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 01/28/2019] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
Identification of unknown chemical entities is a major challenge in metabolomics. To address this challenge, we developed a comprehensive targeted profiling strategy, combining 3 complementary liquid chromatography quadrupole time-of-flight mass spectrometry (LC-QTOF-MS) techniques and in-house accurate mass retention time (AMRT) databases established from commercial standards. This strategy was used to evaluate the effect of nitisinone on the urinary metabolome of patients and mice with alkaptonuria (AKU). Because hypertyrosinemia is a known consequence of nitisinone therapy, we investigated the wider metabolic consequences beyond hypertyrosinemia.
METHODS
A total of 619 standards (molecular weight, 45–1354 Da) covering a range of primary metabolic pathways were analyzed using 3 liquid chromatography methods—2 reversed phase and 1 normal phase—coupled to QTOF-MS. Separate AMRT databases were generated for the 3 methods, comprising chemical name, formula, theoretical accurate mass, and measured retention time. Databases were used to identify chemical entities acquired from nontargeted analysis of AKU urine: match window theoretical accurate mass ±10 ppm and retention time ±0.3 min.
RESULTS
Application of the AMRT databases to data acquired from analysis of urine from 25 patients with AKU (pretreatment and after 3, 12, and 24 months on nitisinone) and 18 HGD−/− mice (pretreatment and after 1 week on nitisinone) revealed 31 previously unreported statistically significant changes in metabolite patterns and abundance, indicating alterations to tyrosine, tryptophan, and purine metabolism after nitisinone administration.
CONCLUSIONS
The comprehensive targeted profiling strategy described here has the potential of enabling discovery of novel pathways associated with pathogenesis and management of AKU.
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Affiliation(s)
- Brendan P Norman
- Musculoskeletal Biology I, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Andrew S Davison
- Musculoskeletal Biology I, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
- Department of Clinical Biochemistry and Metabolic Medicine, Liverpool Clinical Laboratories, Royal Liverpool University Hospitals Trust, Liverpool, UK
| | | | - Anna M Milan
- Musculoskeletal Biology I, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
- Department of Clinical Biochemistry and Metabolic Medicine, Liverpool Clinical Laboratories, Royal Liverpool University Hospitals Trust, Liverpool, UK
| | - Andrew T Hughes
- Musculoskeletal Biology I, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
- Department of Clinical Biochemistry and Metabolic Medicine, Liverpool Clinical Laboratories, Royal Liverpool University Hospitals Trust, Liverpool, UK
| | - Hazel Sutherland
- Musculoskeletal Biology I, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
- School of Exercise Science, Liverpool John Moores University, Liverpool, UK
| | - Jonathan C Jarvis
- School of Exercise Science, Liverpool John Moores University, Liverpool, UK
| | - Norman B Roberts
- Musculoskeletal Biology I, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - James A Gallagher
- Musculoskeletal Biology I, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Lakshminarayan R Ranganath
- Musculoskeletal Biology I, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
- Department of Clinical Biochemistry and Metabolic Medicine, Liverpool Clinical Laboratories, Royal Liverpool University Hospitals Trust, Liverpool, UK
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26
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Barchanska H, Rola R, Szczepankiewicz W, Mrachacz M. LC-MS/MS study of the degradation processes of nitisinone and its by-products. J Pharm Biomed Anal 2019; 171:15-21. [PMID: 30959315 DOI: 10.1016/j.jpba.2019.03.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 03/18/2019] [Accepted: 03/20/2019] [Indexed: 12/14/2022]
Abstract
Nitisinone (2-(2-nitro-4-trifluoromethylbenzoyl)-1,3-cyclohexanedione, NTBC) was the first synthetically produced triketone herbicide. However, its unsatisfactory herbicidal properties, negative impact on the natural environment and the high cost of synthesis have hindered its commercialization as a plant protection agent. Nevertheless, NTBC has become the medical treatment of choice for a rare hereditary metabolic disease -hepatorenal tyrosinemia. Literature review shows that most research on nitisinone focuses on its medical applications, while there are neither in-depth studies of its stability nor its degradation pathways. Therefore, the aim of our study was to employ liquid chromatography coupled with mass spectrometry (LC-MS/MS) to determine the stability of NTBC in different experimental conditions (pH of solution, temperature, time of incubation, ultraviolet radiation), identify its degradation products and determine the stability of the latter. Electrospray ionization (ESI) in the negative ion mode was used as an ionization method and the analytes were detected by multiple reaction monitoring. We show that nitisinone stability increases with increasing pH of the solution. At pH similar to that of gastric juice in the human stomach, two major products of NTBC degradation are formed: 2-amino-4-(trifluoromethyl)benzoic acid (ATFA) and 2-nitro-4-(trifluoromethyl)benzoic acid (NTFA), which show considerable stability under studied conditions. The results of these studies shed new light on the properties of NTBC, therefore contributing to better understanding of possible risks and benefits of its medical application.
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Affiliation(s)
- Hanna Barchanska
- Department of Inorganic Chemistry, Analytical Chemistry and Electrochemistry, Faculty of Chemistry, Silesian University of Technology, B. Krzywoustego 6 Str, 44-100 Gliwice, Poland.
| | - Rafał Rola
- Masdiag - Diagnostic Mass Spectrometry Laboratory, S. Żeromskiego 33 Str, 01-882 Warsaw, Poland
| | - Wojciech Szczepankiewicz
- Department of Organic Chemistry, Bioorganic Chemistry and Biotechnology, Faculty of Chemistry, Silesian University of Technology, B. Krzywoustego Str, 44-100 Gliwice, Poland
| | - Marta Mrachacz
- Department of Inorganic Chemistry, Analytical Chemistry and Electrochemistry, Faculty of Chemistry, Silesian University of Technology, B. Krzywoustego 6 Str, 44-100 Gliwice, Poland
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Abstract
This is an introduction to the special issue on cognitive impairments in inherited metabolic diseases (IMD). It provides an overview of the studies included, focusing on the possibility of selective impairments which could provide unique evidence on the specificity of neural circuitries mediating cognitive functions. It will suggest that these circuitries have different metabolic properties which make them especially apt to carry out certain functions, but also particularly susceptible to certain forms of metabolic disruption. Knowledge of selective impairments is also crucial to properly evaluate the difficulties engendered by individual diseases and track treatment outcomes. IMR research holds the promise of a more complete understanding of cognition, from cellular functioning to behaviour and of further improvements in treatment. Advances, however, will require detailed assessments, comparisons across diseases, and the integration of different levels of explanation. This will be possible only through close collaborations between centres and types of professionals.
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Affiliation(s)
- Cristina Romani
- a School of Life and Health Sciences, Aston University , Birmingham , UK
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28
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Blundell J, Frisson S, Chakrapani A, Kearney S, Vijay S, MacDonald A, Gissen P, Hendriksz C, Olson A. Markers of cognitive function in individuals with metabolic disease: Morquio syndrome and tyrosinemia type III. Cogn Neuropsychol 2019; 35:120-147. [PMID: 29741470 DOI: 10.1080/02643294.2018.1443913] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
We characterized cognitive function in two metabolic diseases. MPS-IVa (mucopolysaccharidosis IVa, Morquio) and tyrosinemia type III individuals were assessed using tasks of attention, language and oculomotor function. MPS-IVa individuals were slower in visual search, but the display size effects were normal, and slowing was not due to long reaction times (ruling out slow item processing or distraction). Maintaining gaze in an oculomotor task was difficult. Results implicated sustained attention and task initiation or response processing. Shifting attention, accumulating evidence and selecting targets were unaffected. Visual search was also slowed in tyrosinemia type III, and patterns in visual search and fixation tasks pointed to sustained attention impairments, although there were differences from MPS-IVa. Language was impaired in tyrosinemia type III but not MPS-IVa. Metabolic diseases produced selective cognitive effects. Our results, incorporating new methods for developmental data and model selection, illustrate how cognitive data can contribute to understanding function in biochemical brain systems.
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Affiliation(s)
- James Blundell
- a School of Psychology , University of Birmingham , Birmingham , UK
| | - Steven Frisson
- a School of Psychology , University of Birmingham , Birmingham , UK
| | | | | | - Suresh Vijay
- b Birmingham Children's Hospital , Birmingham , UK
| | | | - Paul Gissen
- c Great Ormond Street Hospital , London , UK
| | - Chris Hendriksz
- d Steve Biko Academic Unit , University of Pretoria , Pretoria , South Africa
| | - Andrew Olson
- a School of Psychology , University of Birmingham , Birmingham , UK
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MacDonald K, Krishnan A, Cervenka E, Hu G, Guadagno E, Trakadis Y. Biomarkers for major depressive and bipolar disorders using metabolomics: A systematic review. Am J Med Genet B Neuropsychiatr Genet 2019; 180:122-137. [PMID: 30411484 DOI: 10.1002/ajmg.b.32680] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 07/10/2018] [Accepted: 08/15/2018] [Indexed: 12/21/2022]
Abstract
Major depressive disorder (MDD) and bipolar disorder (BD) lack robust biomarkers useful for screening purposes in a clinical setting. A systematic review of the literature was conducted on metabolomic studies of patients with MDD or BD through the use of analytical platforms such as in vivo brain imaging, mass spectrometry, and nuclear magnetic resonance. Our search identified a total of 7,590 articles, of which 266 articles remained for full-text revision. Overall, 249 metabolites were found to be dysregulated with 122 of these metabolites being reported in two or more of the studies included. A list of biomarkers for MDD and BD established from metabolites found to be abnormal, along with the number of studies supporting each metabolite and a comparison of which biological fluids they were reported in, is provided. Metabolic pathways that may be important in the pathophysiology of MDD and BD were identified and predominantly center on glutamatergic metabolism, energy metabolism, and neurotransmission. Using online drug registries, we also illustrate how metabolomics can facilitate the discovery of novel candidate drug targets.
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Affiliation(s)
- Kellie MacDonald
- Department of Human Genetics, McGill University, Montreal, Quebec
| | - Ankur Krishnan
- Department of Human Genetics, McGill University, Montreal, Quebec
| | - Emily Cervenka
- Department of Human Genetics, McGill University, Montreal, Quebec
| | - Grace Hu
- Department of Human Genetics, McGill University, Montreal, Quebec
| | - Elena Guadagno
- McConnell Resource Centre, McGill University Health Centre, Montreal, Quebec
| | - Yannis Trakadis
- Department of Human Genetics, McGill University, Montreal, Quebec.,Department of Medical Genetics, McGill University Health Centre, Montreal, Quebec
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van Ginkel WG, Rodenburg IL, Harding CO, Hollak CEM, Heiner-Fokkema MR, van Spronsen FJ. Long-Term Outcomes and Practical Considerations in the Pharmacological Management of Tyrosinemia Type 1. Paediatr Drugs 2019; 21:413-426. [PMID: 31667718 PMCID: PMC6885500 DOI: 10.1007/s40272-019-00364-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Tyrosinemia type 1 (TT1) is a rare metabolic disease caused by a defect in tyrosine catabolism. TT1 is clinically characterized by acute liver failure, development of hepatocellular carcinoma, renal and neurological problems, and consequently an extremely poor outcome. This review showed that the introduction of 2-(2-nitro-4-trifluoromethylbenzoyl)-1,3-cyclohexanedione (NTBC) in 1992 has revolutionized the outcome of TT1 patients, especially when started pre-clinically. If started early, NTBC can prevent liver failure, renal problems, and neurological attacks and decrease the risk for hepatocellular carcinoma. NTBC has been shown to be safe and well tolerated, although the long-term effectiveness of treatment with NTBC needs to be awaited. The high tyrosine concentrations caused by treatment with NTBC could result in ophthalmological and skin problems and requires life-long dietary restriction of tyrosine and its precursor phenylalanine, which could be strenuous to adhere to. In addition, neurocognitive problems have been reported since the introduction of NTBC, with hypothesized but as yet unproven pathophysiological mechanisms. Further research should be done to investigate the possible relationship between important clinical outcomes and blood concentrations of biochemical parameters such as phenylalanine, tyrosine, succinylacetone, and NTBC, and to develop clear guidelines for treatment and follow-up with reliable measurements. This all in order to ultimately improve the combined NTBC and dietary treatment and limit possible complications such as hepatocellular carcinoma development, neurocognitive problems, and impaired quality of life.
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Affiliation(s)
- Willem G. van Ginkel
- Department of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands
| | - Iris L. Rodenburg
- Department of Dietetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Cary O. Harding
- Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, USA
| | - Carla E. M. Hollak
- Deparment of Endocrinology and Metabolism, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - M. Rebecca Heiner-Fokkema
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Francjan J. van Spronsen
- Department of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands
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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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Davison AS, Norman BP, Smith EA, Devine J, Usher J, Hughes AT, Khedr M, Milan AM, Gallagher JA, Ranganath LR. Serum Amino Acid Profiling in Patients with Alkaptonuria Before and After Treatment with Nitisinone. JIMD Rep 2018; 41:109-117. [PMID: 29754208 DOI: 10.1007/8904_2018_109] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 03/28/2018] [Accepted: 04/13/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Alkaptonuria (AKU) is a rare inherited disorder of the tyrosine metabolic pathway. Our group is evaluating the use of the homogentisic acid-lowering agent nitisinone in patients with AKU. A major biochemical consequence of this treatment is hypertyrosinaemia. Herein we report the concentration of 20 serum amino acids over a 36-month period pre- and post-treatment with nitisinone. METHODS Fasting serum samples were collected at baseline (pre-nitisinone), 3 (2 mg nitisinone every other day), 6, 12, 24 and 36 (2 mg nitisinone daily) months. Amino acids were measured using the Biochrom 30 high-performance liquid chromatography cation exchange system with ninhydrin detection. RESULTS Fifty patients [21 female, mean age (±standard deviation) 54.1 (15.6) years (range 25-75); 29 male, mean age 49.3 (11.6) years (range 22-70 years)] were included. Following treatment mean tyrosine concentrations increased seven- to eight-fold (baseline, 69.8 μmol/L; 3 months, 670.7 μmol/L; 6 months, 666.4 μmol/L; 12 months, 692.9 μmol/L; 24 months, 649.4 μmol/L; 36 months, 724.8 μmol/L, p = <0.001 for all visits compared to baseline).At baseline mean phenylalanine, aspartic acid and arginine were outside the normal reference range. Following treatment the ratios of phenylalanine/tyrosine, phenylalanine/large neutral amino acids, arginine/branched chain amino acids and branched chain/aromatic amino acids decreased (p = <0.05), and the tyrosine/large neutral amino acid ratio increased (p = <0.0001). CONCLUSIONS Marked hypertyrosinaemia was observed following treatment with nitisinone. Noteworthy changes were also observed in the ratio of several amino acids following treatment with nitisinone suggesting that the availability of amino acids for neurotransmitter biosynthesis and liver function may be altered following treatment with nitisinone.
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Affiliation(s)
- A S Davison
- Liverpool Clinical Laboratories, Department of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool University Hospitals Trust, Liverpool, UK.
- Bone and Joint Research Group, Musculoskeletal Biology, University of Liverpool, Liverpool, UK.
| | - B P Norman
- Bone and Joint Research Group, Musculoskeletal Biology, University of Liverpool, Liverpool, UK
| | - E A Smith
- Department of Clinical Biochemistry, Alder Hey Children's Hospital, Liverpool, UK
| | - J Devine
- Liverpool Clinical Laboratories, Department of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool University Hospitals Trust, Liverpool, UK
| | - J Usher
- Liverpool Clinical Laboratories, Department of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool University Hospitals Trust, Liverpool, UK
| | - A T Hughes
- Liverpool Clinical Laboratories, Department of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool University Hospitals Trust, Liverpool, UK
- Bone and Joint Research Group, Musculoskeletal Biology, University of Liverpool, Liverpool, UK
| | - M Khedr
- Liverpool Clinical Laboratories, Department of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool University Hospitals Trust, Liverpool, UK
- Bone and Joint Research Group, Musculoskeletal Biology, University of Liverpool, Liverpool, UK
| | - A M Milan
- Liverpool Clinical Laboratories, Department of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool University Hospitals Trust, Liverpool, UK
- Bone and Joint Research Group, Musculoskeletal Biology, University of Liverpool, Liverpool, UK
| | - J A Gallagher
- Bone and Joint Research Group, Musculoskeletal Biology, University of Liverpool, Liverpool, UK
| | - L R Ranganath
- Liverpool Clinical Laboratories, Department of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool University Hospitals Trust, Liverpool, UK
- Bone and Joint Research Group, Musculoskeletal Biology, University of Liverpool, Liverpool, UK
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Collaborative Research: An Advanced Practice Nurse's Experience in Genome Research and Treatment. CLIN NURSE SPEC 2018; 31:191-194. [PMID: 28594669 DOI: 10.1097/nur.0000000000000303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Moore ME, Koenig AE, Hillgartner MA, Otap CC, Barnby E, MacGregor GG. Abnormal social behavior in mice with tyrosinemia type I is associated with an increase of myelin in the cerebral cortex. Metab Brain Dis 2017; 32:1829-1841. [PMID: 28712060 DOI: 10.1007/s11011-017-0071-8] [Citation(s) in RCA: 5] [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: 04/24/2017] [Accepted: 07/11/2017] [Indexed: 12/26/2022]
Abstract
Hereditary tyrosinemia type I (HT1) is caused by mutations in the fumarylacetoacetate hydrolase (FAH) gene, the template for the final enzyme in the tyrosine catabolism pathway. If left untreated this deficiency of functional FAH leads to a buildup of toxic metabolites that can cause liver disease, kidney dysfunction and high mortality. The current treatment with the drug NTBC prevents the production of these metabolites and has consequently increased the survival rate in HT1 children. As a result of this increased survival, long term complications of HT1 are now being observed, including slower learning, impaired cognition and altered social behavior. We studied a mouse model of HT1 to gain insight into the effects of HT1 and treatment with NTBC on social behavior in mice. We showed that mice with HT1 display abnormal social behavior in that they spend more time in the absence of another mouse and do not discriminate between a novel mouse and an already familiar mouse. This altered behavior was due to HT1 and not treatment with NTBC. Quantification of cerebral cortex myelin in mice with HT1 showed a two to threefold increase in myelin expression. Our findings suggest that absence of FAH expression in the brain produces an altered brain biochemistry resulting in increased expression of myelin. This increase in myelination could lead to abnormal action potential velocity and altered neuronal connections that provide a mechanism for the altered learning, social behavior and cognitive issues recently seen in HT1.
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Affiliation(s)
- Marissa E Moore
- Department of Biological Sciences, University of Alabama in Huntsville, SST 361, 301 Sparkman Dr, Huntsville, AL, 35899, USA
| | - Ashton E Koenig
- Department of Biological Sciences, University of Alabama in Huntsville, SST 361, 301 Sparkman Dr, Huntsville, AL, 35899, USA
| | - Megan A Hillgartner
- Department of Biological Sciences, University of Alabama in Huntsville, SST 361, 301 Sparkman Dr, Huntsville, AL, 35899, USA
| | - Christopher C Otap
- Department of Biological Sciences, University of Alabama in Huntsville, SST 361, 301 Sparkman Dr, Huntsville, AL, 35899, USA
| | - Elizabeth Barnby
- College of Nursing, University of Alabama in Huntsville, 1610 Ben Graves Drive, Huntsville, AL, 35899, USA
| | - Gordon G MacGregor
- Department of Biological Sciences, University of Alabama in Huntsville, SST 361, 301 Sparkman Dr, Huntsville, AL, 35899, USA.
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Davison AS, Norman B, Milan AM, Hughes AT, Khedr M, Rovensky J, Gallagher JA, Ranganath LR. Assessment of the Effect of Once Daily Nitisinone Therapy on 24-h Urinary Metadrenalines and 5-Hydroxyindole Acetic Acid Excretion in Patients with Alkaptonuria After 4 Weeks of Treatment. JIMD Rep 2017; 41:1-10. [PMID: 29147990 PMCID: PMC6122050 DOI: 10.1007/8904_2017_72] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 10/23/2017] [Accepted: 10/27/2017] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND One of the major metabolic consequences of using nitisinone to treat patients with alkaptonuria is that circulating tyrosine concentrations increase. As tyrosine is required for the biosynthesis of catecholamine neurotransmitters, it is possible that their metabolism is altered as a consequence. Herein we report the 24-h urinary excretion of normetadrenaline (NMA), metadrenaline (MA), 3-methoxytyramine (3-MT) (catecholamine metabolites) and 5-hydroxyindole acetic acid (5-HIAA, metabolite of serotonin) in a cohort of AKU patients before and after a 4-week treatment trial with nitisinone. MATERIALS AND METHODS 24 h urinary excretions of NMA, MA, 3-MT and 5-HIAA were determined by liquid chromatography tandem mass spectrometry. Interassay coefficient of variation was <10% for all analytes measured, at all concentrations tested. RESULTS Urine samples were assayed at baseline (pre-nitisinone, n = 36) and 4 weeks later; 7 received no nitisinone (4 male, mean age (±SD) 46.3 (16.4) years), and 29 received a daily dose of nitisinone [1 mg (n = 7, 6 male, mean age 45.9 (10.9) years), 2 mg (n = 8, 5 male, mean age 43.9 (13.7) years), 4 mg (n = 8, 5 male, mean age 47.3 (10.7) years) and 8 mg (n = 6, 4 male, mean age 53.8 (8.3) years)]. 3-MT concentrations increase significantly (p < 0.01, at all doses) following nitisinone therapy but not in a dose-dependent manner. NMA concentrations decreased (p < 0.05, at all doses) following nitisinone therapy at all doses. 5-HIAA concentrations decreased following nitisinone therapy and were significantly lower at a daily dose of 8 mg only (p < 0.05). CONCLUSIONS This study shows that catecholamine and serotonin metabolism is altered by treatment with nitisinone.
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Affiliation(s)
- A. S. Davison
- Department of Clinical Biochemistry and Metabolic Medicine, Liverpool Clinical Laboratories, Royal Liverpool University Hospitals Trust, Liverpool, UK ,Bone and Joint Research Group, Musculoskeletal Biology, University of Liverpool, Liverpool, UK
| | - B. Norman
- Bone and Joint Research Group, Musculoskeletal Biology, University of Liverpool, Liverpool, UK
| | - A. M. Milan
- Department of Clinical Biochemistry and Metabolic Medicine, Liverpool Clinical Laboratories, Royal Liverpool University Hospitals Trust, Liverpool, UK ,Bone and Joint Research Group, Musculoskeletal Biology, University of Liverpool, Liverpool, UK
| | - A. T. Hughes
- Department of Clinical Biochemistry and Metabolic Medicine, Liverpool Clinical Laboratories, Royal Liverpool University Hospitals Trust, Liverpool, UK ,Bone and Joint Research Group, Musculoskeletal Biology, University of Liverpool, Liverpool, UK
| | - M. Khedr
- Department of Clinical Biochemistry and Metabolic Medicine, Liverpool Clinical Laboratories, Royal Liverpool University Hospitals Trust, Liverpool, UK ,Bone and Joint Research Group, Musculoskeletal Biology, University of Liverpool, Liverpool, UK
| | - J. Rovensky
- National Institute of Rheumatic Diseases, Piešťany, Slovakia
| | - J. A. Gallagher
- Bone and Joint Research Group, Musculoskeletal Biology, University of Liverpool, Liverpool, UK
| | - L. R. Ranganath
- Department of Clinical Biochemistry and Metabolic Medicine, Liverpool Clinical Laboratories, Royal Liverpool University Hospitals Trust, Liverpool, UK ,Bone and Joint Research Group, Musculoskeletal Biology, University of Liverpool, Liverpool, UK
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Three Cases of Hereditary Tyrosinaemia Type 1: Neuropsychiatric Outcomes and Brain Imaging Following Treatment with NTBC. JIMD Rep 2017. [PMID: 29143197 DOI: 10.1007/8904_2017_69] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2023] Open
Abstract
AIM To examine neuropsychiatric outcomes in adults with hereditary tyrosinaemia type I (HT-1), treated with 2-(2-nitro-4-trifluoromethylbenzoyl)-1,3-cyclohexanedione (NTBC) and correlate these with functional imaging as well as with tyrosine and phenylalanine-tyrosine (Phe:Tyr) ratios. DESIGN We retrospectively reviewed the medical records of three adult HT-1 patients with a particular focus on their FDG PET/CT brain scans, neuropsychiatric assessment (including neurocognitive assessment and mood and anxiety ratings) as well as mean tyrosine and phenylalanine levels and Phe:Tyr ratios for 3-month period. The patients had been referred to a specialist joint inherited metabolic disorder and neuropsychiatry clinic. They were all on NTBC; two since 6 weeks of age, and one since 9 years of age. RESULTS All patients performed below the expectation on the formal neurocognitive testing and had raised plasma tyrosine levels and reduced plasma Phe:Tyr ratios. FDG PET/CT-brain scans were normal in two patients and the third patient (treated with NTBC from 6 weeks) had reduced metabolism in temporal and medial frontal areas bilaterally which correlated with the neurocognitive performance. CONCLUSIONS All three HT-1 patients treated with NTBC had high tyrosine levels, reduced Phe:Tyr ratios and underperformed in neurocognitive testing regardless of the point when the NTBC was first started. One had imaging abnormalities which also correlated with neurocognitive performance. The patient who struggled the most in neurocognitive testing had the highest average plasma tyrosine levels and the lowest Phe:Tyr ratio. Overall, these cases appear to support the previous hypothesis that either the high tyrosine levels or abnormal phenylalanine hydroxylase (PAH) function may well be the causative factor for poor neurocognitive performance. Further systematic, multi-centre studies with a longer follow-up are required to further clarify the relationship between HT-1, NTBC treatment, tyrosine and phenylalanine levels and neurocognitive outcomes.
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Presumptive brain influx of large neutral amino acids and the effect of phenylalanine supplementation in patients with Tyrosinemia type 1. PLoS One 2017; 12:e0185342. [PMID: 28949985 PMCID: PMC5614617 DOI: 10.1371/journal.pone.0185342] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 09/11/2017] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Hereditary Tyrosinemia type 1 (HT1) is a rare metabolic disease caused by a defect in the tyrosine degradation pathway. Current treatment consists of 2-(2-nitro-4-trifluoromethylbenoyl)-1,3-cyclohexanedione (NTBC) and a tyrosine and phenylalanine restricted diet. Recently, neuropsychological deficits have been seen in HT1 patients. These deficits are possibly associated with low blood phenylalanine concentrations and/or high blood tyrosine concentrations. Therefore, the aim of the present study was threefold. Firstly, we aimed to calculate how the plasma amino acid profile in HT1 patients may influence the presumptive brain influx of all large neutral amino acids (LNAA). Secondly, we aimed to investigate the effect of phenylalanine supplementation on presumptive brain phenylalanine and tyrosine influx. Thirdly, we aimed to theoretically determine minimal target plasma phenylalanine concentrations in HT1 patient to ensure adequate presumptive brain phenylalanine influx. METHODS Data of plasma LNAA concentrations were obtained. In total, 239 samples of 9 HT1 children, treated with NTBC, diet, and partly with phenylalanine supplementation were collected together with 596 samples of independent control children. Presumptive brain influx of all LNAA was calculated, using Michaelis-Menten parameters (Km) and Vmax-values obtained from earlier articles. RESULTS In HT1 patients, plasma concentrations and presumptive brain influx of tyrosine were higher. However, plasma and especially brain influx of phenylalanine were lower in HT1 patients. Phenylalanine supplementation did not only tend to increase plasma phenylalanine concentrations, but also presumptive brain phenylalanine influx, despite increased plasma tyrosine concentrations. However, to ensure sufficient brain phenylalanine influx in HT1 patients, minimal plasma phenylalanine concentrations may need to be higher than considered thus far. CONCLUSION This study clearly suggests a role for disturbed brain LNAA biochemistry, which is not well reflected by plasma LNAA concentrations. This could play a role in the pathophysiology of the neuropsychological impairments in HT1 patients and may have therapeutic implications.
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Diagnosis and treatment of tyrosinemia type I: a US and Canadian consensus group review and recommendations. Genet Med 2017; 19:S1098-3600(21)04765-1. [PMID: 28771246 PMCID: PMC5729346 DOI: 10.1038/gim.2017.101] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 04/28/2017] [Indexed: 12/19/2022] Open
Abstract
Tyrosinemia type I (hepatorenal tyrosinemia, HT-1) is an autosomal recessive condition resulting in hepatic failure with comorbidities involving the renal and neurologic systems and long term risks for hepatocellular carcinoma. An effective medical treatment with 2-[2-nitro-4-trifluoromethylbenzoyl]-1,3-cyclohexanedione (NTBC) exists but requires early identification of affected children for optimal long-term results. Newborn screening (NBS) utilizing blood succinylacetone as the NBS marker is superior to observing tyrosine levels as a way of identifying neonates with HT-1. If identified early and treated appropriately, the majority of affected infants can remain asymptomatic. A clinical management scheme is needed for infants with HT-1 identified by NBS or clinical symptoms. To this end, a group of 11 clinical practitioners, including eight biochemical genetics physicians, two metabolic dietitian nutritionists, and a clinical psychologist, from the United States and Canada, with experience in providing care for patients with HT-1, initiated an evidence- and consensus-based process to establish uniform recommendations for identification and treatment of HT-1. Recommendations were developed from a literature review, practitioner management survey, and nominal group process involving two face-to-face meetings. There was strong consensus in favor of NBS for HT-1, using blood succinylacetone as a marker, followed by diagnostic confirmation and early treatment with NTBC and diet. Consensus recommendations for both immediate and long-term clinical follow-up of positive diagnoses via both newborn screening and clinical symptomatic presentation are provided.
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Diagnosing Hepatorenal Tyrosinaemia in Europe: Newborn Mass Screening Versus Selective Screening. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017. [PMID: 28755190 DOI: 10.1007/978-3-319-55780-9_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Hepatorenal tyrosinaemia (HT1) is a serious condition that used to be fatal before the advent of nitisinone (NTBC, Orfadine®) as a therapeutic option. We have recently shown that selective screening is inadequate as initial symptoms are often uncharacteristic which leads to a considerable delay in diagnosis and treatment. This has a negative impact on morbidity and mortality as well as long-term outcome. For example, the odds ratio to develop hepatocellular carcinoma is 12.7 when treatment is initiated after the first birthday compared to start of treatment in the neonatal period. Timely diagnosis is only possible when neonatal mass screening is operational. HT1 meets all the criteria for neonatal mass screening at a clinical and analytical level. The natural course of the disease is well known, clinically there is a latent phase in most patients when presymptomatic treatment can be initiated. There are no mild phenotypes which do not require treatment. Using succinylacetone as the screening parameter a highly specific and sensitive test is available with acceptable financial burden. Neonatal mass screening for HT1 is acceptable to the target population as it can be performed simultaneously with the already existing screening tests in dried blood, there are no false negative and false positive cases and the financial burden to the health system is moderate. An efficient treatment is available with nitisinone and protein-reduced diet supplemented with special amino acid mixtures. Despite compelling evidence in favour of a neonatal mass screening for HT1 only 57% of European centres taking part in our recent cross-sectional study have included HT1 in their newborn screening programme.
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Das AM. Clinical utility of nitisinone for the treatment of hereditary tyrosinemia type-1 (HT-1). APPLICATION OF CLINICAL GENETICS 2017; 10:43-48. [PMID: 28769581 PMCID: PMC5533484 DOI: 10.2147/tacg.s113310] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Medical therapy for hereditary hepatorenal tyrosinemia (hereditary tyrosinemia type 1, HT-1) with nitisinone was discovered incidentally, and is a by-product of agrochemistry. It blocks the catabolic pathway of tyrosine, thereby leading to a reduction in the accumulation of toxic metabolites in HT-1. It has to be combined with a low-protein diet supplemented with amino acid mixtures devoid of tyrosine and phenylalanine. This treatment option has completely changed the clinical course of patients suffering from HT-1 who used to die in the first few months to years of life from liver failure, renal dysfunction, and/or hepatocellular carcinoma (HCC). It is essential to start nitisinone therapy early in life to avoid sequelae; beginning treatment in the newborn period is ideal. As initial clinical symptoms of HT-1 are often atypical and because there is a clinically latent phase during the first few months of life in many patients, newborn screening is required to secure early diagnosis. Succinylacetone in blood is a reliable screening parameter whereas tyrosine is neither specific nor sensitive. Especially HCC, but also liver and kidney dysfunction, rickets, and neurological crises can be prevented in most patients if nitisinone therapy is started in the newborn period. It is essential to adhere to a low-protein diet to avoid tyrosine toxicity. Reversible eye symptoms may occur as a side-effect of nitisinone, but other side effects are rare. Neurocognitive development is impaired in some patients, and the reason for this is unclear. Metabolic monitoring includes measurement of tyrosine, succinylacetone, and nitisinone concentrations in blood.
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Affiliation(s)
- Anibh Martin Das
- Department of Pediatrics, Hannover Medical School, Hannover, Germany
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Long-term cognitive functioning in individuals with tyrosinemia type 1 treated with nitisinone and protein-restricted diet. Mol Genet Metab Rep 2017; 11:12-16. [PMID: 28377889 PMCID: PMC5369864 DOI: 10.1016/j.ymgmr.2017.01.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 01/24/2017] [Accepted: 01/26/2017] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Tyrosinemia Type 1 (HT1) is an autosomal recessive disorder caused by a defect in the enzyme fumarylacetoacetate hydroxylase in the tyrosine pathway. Implementation of nitisinone (NTBC) treatment has dramatically improved survival rate of individuals with HT1, yet recent reports on cognitive impairment in treated patients exist. AIMS Describe long-term neurocognitive outcome individuals with HT1 treated with nitisinone and protein restricted diet. METHODOLOGY Twelve individuals with HT1 were analyzed with respect to psychomotor development and cognitive functioning using standardized psychometric tests. Plasma tyrosine and phenylalanine concentrations were also collected and analyzed, as part of the regular HT1 follow up program in our clinic. RESULTS Delayed performance in Bayley scale mental developmental index (MDI) was identified in 29% to 38% of the patients assessed at different ages. At preschool age, mean full scale IQ (FSIQ) was 88 ± 16; six out of nine assessed children preformed within normal range, and one child presented with intellectual disability. At school age mean FSIQ was 79 ± 18, three out of nine children preformed within normal range and two showed intellectual disability. Repeated measures showed IQ decline over time in four out of eight patients, all of whom presented with symptoms in their first months of life. Patients that showed no progressive IQ decline were 8 months or older at diagnosis, with a mean age of 17 months. Significant correlation between Phe/Tyr ratio and FSIQ at school age was identified (r = - 0.689; p < 0.044). CONCLUSION Some patients with HT1 treated with nitisinone and protein restricted diet are at risk of presenting developmental delay and impaired cognitive functioning. Patients with early onset of symptoms could be at risk for progressive cognitive functioning decline over time.
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van Dam E, Daly A, Venema-Liefaard G, van Rijn M, Derks TGJ, McKiernan PJ, Rebecca Heiner-Fokkema M, MacDonald A, van Spronsen FJ. What Is the Best Blood Sampling Time for Metabolic Control of Phenylalanine and Tyrosine Concentrations in Tyrosinemia Type 1 Patients? JIMD Rep 2017; 36:49-57. [PMID: 28120161 DOI: 10.1007/8904_2016_37] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 11/26/2016] [Accepted: 12/12/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Treatment of hereditary tyrosinemia type 1 with nitisinone and phenylalanine and tyrosine restricted diet has largely improved outcome, but the best blood sampling time for assessment of metabolic control is not known. AIM To study diurnal and day-to-day variation of phenylalanine and tyrosine concentrations in tyrosinemia type 1 patients. METHODS Eighteen tyrosinemia type 1 patients aged >1 year (median age 7.9 years; range 1.6-20.7) were studied. Capillary blood samples were collected 4 times a day (T1: pre-breakfast, T2: pre-midday meal, T3: before evening meal, and T4: bedtime) for 3 days. Linear mixed-effect models were used to investigate diurnal and day-to-day variation of both phenylalanine and tyrosine. RESULTS The coefficients of variation of phenylalanine and tyrosine concentrations were the lowest on T1 (13.8% and 14.1%, respectively). Tyrosine concentrations did not significantly differ between the different time points, but phenylalanine concentrations were significantly lower at T2 and T3 compared to T1 (50.1 μmol/L, 29.8 μmol/L, and 37.3 μmol/L, respectively). CONCLUSION Our results indicated that for prevention of too low phenylalanine and too high tyrosine concentrations, measurement of phenylalanine and tyrosine pre-midday meal would be best, since phenylalanine concentrations are the lowest on that time point. Our results also indicated that whilst blood tyrosine concentrations were stable over 24 h, phenylalanine fluctuated. Day-to-day variation was most stable after an overnight fast for both phenylalanine and tyrosine. Therefore, in tyrosinemia type 1 patients the most reliable time point for measuring phenylalanine and tyrosine concentrations to enable interpretation of metabolic control is pre-breakfast.
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Affiliation(s)
- Esther van Dam
- Department of Dietetics, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, The Netherlands.
| | - Anne Daly
- Birmingham Children's Hospital, Birmingham, UK
| | - Gineke Venema-Liefaard
- Department of Dietetics, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, The Netherlands
| | - Margreet van Rijn
- Department of Dietetics, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, The Netherlands
| | - Terry G J Derks
- Department of Pediatrics, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, The Netherlands
| | | | - M Rebecca Heiner-Fokkema
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Francjan J van Spronsen
- Department of Pediatrics, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, The Netherlands
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Neurological and Neuropsychological Problems in Tyrosinemia Type I Patients. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 959:111-122. [PMID: 28755189 DOI: 10.1007/978-3-319-55780-9_10] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Clinically, Hereditary Tyrosinemia type I (HTI) is especially characterized by severe liver dysfunction in early life. However, recurrent neurological crises are another main finding in these patients when they are treated with a tyrosine and phenylalanine restricted diet only. This is caused by the accumulation of δ-aminolevulinic acid due to the inhibitory effect of succinylacetone on the enzyme that metabolizes δ-aminolevulinic acid. Due to the biochemical and clinical resemblance of these neurological crises and acute intermittent porphyria, this group of symptoms in HTI patients is mostly called porphyria-like-syndrome. The neurological crises in HTI patients disappeared after the introduction of treatment with 2-(2 nitro-4-3 trifluoro-methylbenzoyl)-1, 3-cyclohexanedione (NTBC). However, if NTBC treatment is stopped for a while, severe neurological dysfunction will reappear.If NTBC treatment is started early and given continuously, all clinical problems seem to be solved. However, recent research findings indicate that HTI patients have a non-optimal neurocognitive outcome, showing (among others) a lower IQ and impaired executive functioning and social cognition. Unfortunately the exact neuropsychological profile of these HTI patients is not known yet, neither are the exact pathophysiological mechanisms underlying these impairments. It may be hypothesized that the biochemical changes such as high blood tyrosine or low blood phenylalanine concentrations are important in this respect, but an direct toxic effect of NTBC or production of toxic metabolites (that previously characterized the disease before introduction of NTBC) cannot be excluded either. This chapter discusses the neurological and neuropsychological symptoms associated with HTI in detail. An extended section on possible underlying pathophysiological mechanisms of such symptoms is also included.
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Gokay S, Ustkoyuncu PS, Kardas F, Kendirci M. The outcome of seven patients with hereditary tyrosinemia type 1. J Pediatr Endocrinol Metab 2016; 29:1151-1157. [PMID: 27682708 DOI: 10.1515/jpem-2015-0471] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 07/18/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Hereditary tyrosinemia type 1 (HT1) is a rare, inborn error of tyrosine metabolism. It is a fatal disorder without treatment. Early treatment may prevent acute liver failure, renal dysfunction, liver cirrhosis, hepatocellular carcinoma (HCC) and improves survival. The aim of the present study is to describe the clinical, biochemical, imaging and follow-up of seven patients with HT1 and to define the consequences of the late and interrupted treatment. METHODS A retrospective study was carried out with seven HT1 patients. RESULTS The median age at onset of clinical symptoms was 11.2 months (range, 3-28 months) and the median age at diagnosis was 22 months (range, 6-58 months). Liver enzymes and coagulation parameters were back to normal in all symptomatic patients in about 2 weeks. Alfa-fetoprotein (AFP) levels were normalized within the first year of therapy. Hypoechoic nodule formation was detected in two of the seven patients despite drug treatment without an increase of AFP and any dysplastic changes in the biopsies. One patient died due to metastatic HCC because of the late diagnosis and the poor compliance of the follow-up. CONCLUSIONS This study showed once again that adherence to the treatment and a follow-up schedule of the patients are very important. Also it should not be forgotten that nodule formation can occur despite nitisinone treatment without an increase of AFP. Despite nitisinone treatment, HT1 patients still carry the risk of HCC. HCC must be detected before metastasis to other organs otherwise, patients may lose the chance for liver transplantation.
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Hillgartner MA, Coker SB, Koenig AE, Moore ME, Barnby E, MacGregor GG. Tyrosinemia type I and not treatment with NTBC causes slower learning and altered behavior in mice. J Inherit Metab Dis 2016; 39:673-682. [PMID: 27271696 DOI: 10.1007/s10545-016-9949-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 05/11/2016] [Accepted: 05/12/2016] [Indexed: 12/12/2022]
Abstract
Tyrosinemia type I is a recessive inborn error of metabolism caused by mutations in the fumarylacetoacetate hydrolase (FAH) gene, coding for the final enzyme in the metabolism of tyrosine. This renders FAH nonfunctional and without treatment, toxic metabolites accumulate causing liver and kidney damage. Introduction of the drug NTBC in 2002 offered a treatment which inhibits an upstream enzyme, preventing the production of the toxic metabolites. There is now a long-term survival rate of greater than 90 % in children, but there are reports of lower cognitive function and IQ as well as schooling and behavioral problems in these children. We studied a mouse model of tyrosinemia type I to gain insight into the effects of tyrosinemia type I and treatment with NTBC on mouse learning, memory, and behavior. In the Barnes maze, visual and spatial cues can be used by mice to remember the location of a dark escape box. The primary time, distance, and strategy taken by the mice to locate the escape box is a measure of learning and memory. Our findings show that mice with tyrosinemia type I were slower to learn than wild-type mice treated with NTBC and made more mistakes, but were capable of learning and storing long-term memory. After learning the location of the target hole, mice with tyrosinemia type I respond differently to a change in location and were less flexible in learning the new target hole location. Our findings suggest that this slower learning and cognitive difference is caused by tyrosinemia type I and not by the treatment with NTBC.
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Affiliation(s)
- Megan A Hillgartner
- Department of Biological Science, University of Alabama in Huntsville, Huntsville, AL, 35899, USA
| | - Sarah B Coker
- Department of Biological Science, University of Alabama in Huntsville, Huntsville, AL, 35899, USA
| | - Ashton E Koenig
- Department of Biological Science, University of Alabama in Huntsville, Huntsville, AL, 35899, USA
| | - Marissa E Moore
- Department of Biological Science, University of Alabama in Huntsville, Huntsville, AL, 35899, USA
| | - Elizabeth Barnby
- College of Nursing, University of Alabama in Huntsville, 1610 Ben Graves Drive, Huntsville, AL, 35899, USA
| | - Gordon G MacGregor
- Department of Biological Science, University of Alabama in Huntsville, Huntsville, AL, 35899, USA.
- , SST 361, 301 Sparkman Dr, Huntsville, AL, 35899, USA.
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van Ginkel WG, Jahja R, Huijbregts SCJ, Daly A, MacDonald A, De Laet C, Cassiman D, Eyskens F, Körver-Keularts IMLW, Goyens PJ, McKiernan PJ, van Spronsen FJ. Neurocognitive outcome in tyrosinemia type 1 patients compared to healthy controls. Orphanet J Rare Dis 2016; 11:87. [PMID: 27356512 PMCID: PMC4928338 DOI: 10.1186/s13023-016-0472-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 06/17/2016] [Indexed: 01/07/2023] Open
Abstract
Background Hereditary Tyrosinemia type 1 (HT1) is a rare metabolic disorder caused by a defect in the enzyme Fumarylacetoacetate Hydrolase. Due to this defect, toxic products accumulate which, in turn, cause liver and kidney dysfunction. Treatment with 2-(2-nitro-4-trifluoromethylbenoyl)-1,3-cyclohexanedione (NTBC) and diet has diminished these problems, but recent data indicate that HT1 patients have neurocognitive problems. However, the neuropsychological profile of these patients is unknown. Therefore, this study aimed to investigate this neuropsychological profile by comparing HT1 patients with healthy controls. Methods Neurocognitive testing was performed in a heterogeneous group of 19 NTBC and dietary treated HT1 patients (five female, fourteen male; mean age 12.9 ± 4.8 years; range 7.9–23.6 years) and 19 age and gender matched controls (five female, fourteen male; mean age 13.2 ± 4.6 years; range 8.1–24.8 years). IQ scores were estimated and all participants performed the Amsterdam Neuropsychological Tasks, measuring executive functions (inhibition, cognitive flexibility and working memory) and social cognition (face recognition and identification of facial emotions). Results HT1 patients showed poorer estimated IQ, executive functioning (working memory and cognitive flexibility), and social cognition compared to healthy controls. Lower IQ scores in HT1 patients were mostly unrelated to scores on executive function- and social cognition tasks and therefore did not account for group differences in these domains. Further analyses within the HT1 patient group (comparing different groups of patients based on the age at diagnosis and the clinical symptoms at diagnosis) did not reveal any significant results. The duration of NTBC treatment was negatively correlated with IQ. Conclusions Despite the heterogeneity of the patient group, these data clearly show that IQ, executive functioning and social cognition are affected in HT1 patients, and that IQ screening is not sufficient for cognitive monitoring of these patients. Further research should focus on the underlying pathophysiological mechanisms of these impairments to consequently try to improve treatment strategies.
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Affiliation(s)
- Willem G van Ginkel
- University of Groningen, Beatrix Children's Hospital, University Medical Center Groningen, 9700 RB, Groningen, The Netherlands
| | - Rianne Jahja
- University of Groningen, Beatrix Children's Hospital, University Medical Center Groningen, 9700 RB, Groningen, The Netherlands
| | | | - Anne Daly
- Birmingham Children's Hospital, Birmingham, UK
| | | | - Corinne De Laet
- University Children's Hospital Queen Fabiola, Free University of Brussels, Brussels, Belgium
| | - David Cassiman
- University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
| | - François Eyskens
- Queen Paola Children's Hospital, University of Antwerp, Antwerp, Belgium
| | | | - Philippe J Goyens
- University Children's Hospital Queen Fabiola, Free University of Brussels, Brussels, Belgium
| | | | - Francjan J van Spronsen
- University of Groningen, Beatrix Children's Hospital, University Medical Center Groningen, 9700 RB, Groningen, The Netherlands.
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Laschi M, Bernardini G, Dreassi E, Millucci L, Geminiani M, Braconi D, Marzocchi B, Botta M, Manetti F, Santucci A. Inhibition ofpara-Hydroxyphenylpyruvate Dioxygenase by Analogues of the Herbicide Nitisinone As a Strategy to Decrease Homogentisic Acid Levels, the Causative Agent of Alkaptonuria. ChemMedChem 2016; 11:674-8. [DOI: 10.1002/cmdc.201500578] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Indexed: 12/15/2022]
Affiliation(s)
- Marcella Laschi
- Department of Biotechnology, Chemistry and Pharmacy; Università degli Studi di Siena; Via Aldo Moro 2 53100 Siena Italy
| | - Giulia Bernardini
- Department of Biotechnology, Chemistry and Pharmacy; Università degli Studi di Siena; Via Aldo Moro 2 53100 Siena Italy
| | - Elena Dreassi
- Department of Biotechnology, Chemistry and Pharmacy; Università degli Studi di Siena; Via Aldo Moro 2 53100 Siena Italy
| | - Lia Millucci
- Department of Biotechnology, Chemistry and Pharmacy; Università degli Studi di Siena; Via Aldo Moro 2 53100 Siena Italy
| | - Michela Geminiani
- Department of Biotechnology, Chemistry and Pharmacy; Università degli Studi di Siena; Via Aldo Moro 2 53100 Siena Italy
| | - Daniela Braconi
- Department of Biotechnology, Chemistry and Pharmacy; Università degli Studi di Siena; Via Aldo Moro 2 53100 Siena Italy
| | - Barbara Marzocchi
- Department of Biotechnology, Chemistry and Pharmacy; Università degli Studi di Siena; Via Aldo Moro 2 53100 Siena Italy
| | - Maurizio Botta
- Department of Biotechnology, Chemistry and Pharmacy; Università degli Studi di Siena; Via Aldo Moro 2 53100 Siena Italy
| | - Fabrizio Manetti
- Department of Biotechnology, Chemistry and Pharmacy; Università degli Studi di Siena; Via Aldo Moro 2 53100 Siena Italy
| | - Annalisa Santucci
- Department of Biotechnology, Chemistry and Pharmacy; Università degli Studi di Siena; Via Aldo Moro 2 53100 Siena Italy
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McKiernan PJ, Preece MA, Chakrapani A. Outcome of children with hereditary tyrosinaemia following newborn screening. Arch Dis Child 2015; 100:738-41. [PMID: 25564536 DOI: 10.1136/archdischild-2014-306886] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 12/15/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Nitisinone has transformed the management of hereditary tyrosinaemia type 1 (HT1). However, the risk of developing hepatocellular carcinoma is related to the age at which treatment is commenced. Little data on the outcome of children treated pre-emptively exist. AIM To describe the outcome of children with HT1 treated with nitisinone following selective newborn screening (NBS) and to compare their outcome with index siblings who had presented clinically. SUBJECTS 12 children with HT1 were detected by NBS. Seven children were screened for HT1 because of an affected sibling (n=5). Four children were detected due to raised tyrosine concentrations on routine NBS and one child was born in a country with universal NBS for HT1. OUTCOME Nitisinone was commenced at 4 (1-52) days old. 6 children had an initial coagulopathy which resolved after 4 (1-7) days treatment. Currently at median age 8.5 (3-12.5) years all are clinically normal, with normal liver function tests and imaging. Those of school age are in normal classes but four have reported learning difficulties. Five index siblings presented clinically with acute liver failure (four) and chronic liver disease (one) at median 4 (1.5-17) months. One died of liver failure prior to nitisinone's availability. Four were treated with nitisinone; one failed to respond and underwent liver transplantation and three responded. One responder died from complications of prematurity and the remaining two have compensated liver disease. SUMMARY Children with HT1 treated with nitisinone following NBS have an excellent outcome. CONCLUSIONS Universal NBS for HT1 should be introduced in the UK.
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Affiliation(s)
- P J McKiernan
- Liver Unit and Department of Inherited Metabolic Disease, Birmingham Children's Hospital, Birmingham, UK
| | - Mary Anne Preece
- Liver Unit and Department of Inherited Metabolic Disease, Birmingham Children's Hospital, Birmingham, UK
| | - Anupam Chakrapani
- Liver Unit and Department of Inherited Metabolic Disease, Birmingham Children's Hospital, Birmingham, UK
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Hadžić N, Vara R. Neonatal screening for hereditary tyrosinaemia: are we there yet? Arch Dis Child 2015; 100:720-1. [PMID: 25957320 DOI: 10.1136/archdischild-2015-308265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 04/16/2015] [Indexed: 11/03/2022]
Affiliation(s)
- Nedim Hadžić
- Paediatric Centre for Hepatology, Gastroenterology and Nutrition, King's College Hospital, London, UK
| | - Roshni Vara
- Metabolic Medicine, Evelina Children's Hospital, London, UK
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Zeybek ACA, Kiykim E, Soyucen E, Cansever S, Altay S, Zubarioglu T, Erkan T, Aydin A. Hereditary tyrosinemia type 1 in Turkey: twenty year single-center experience. Pediatr Int 2015; 57:281-9. [PMID: 25223216 DOI: 10.1111/ped.12503] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 08/28/2014] [Accepted: 09/09/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hereditary tyrosinemia type 1(HT1) is a chronic disorder leading to severe hepatic, renal and peripheral nerve damage if left untreated. Despite nitisinone treatment HT1 still carries the risks of hepatocellular carcinoma (HCC) and neuropsychological outcome. METHODS A retrospective single center study was carried out based on the phenotype, therapy and outcome in 38 Turkish patients with HT1 diagnosed during the last 20 years. RESULTS None of the patients was diagnosed on newborn screening. The patients were grouped according to acute, subacute and chronic forms of the disorder. The main clinical manifestations were hepatosplenomegaly, liver and renal tubular dysfunction. Thirty-six patients were treated with nitisinone. The mean duration of nitisinone treatment was 64 months and the mean dosage was 1.2 mg/kg/day. Dietary compliance problems were frequent. Eleven patients had cognitive evaluation (mean total IQ, 84 points). Six patients had living donor liver transplantation despite nitisinone treatment: three due to suspected HCC, two for non-compliance to diet, and one for both, at a median age of 90 months. CONCLUSION Nitisinone treatment is effective and improves both short- and long-term prognosis of HT1. Early diagnosis on newborn screening is needed because delay in treatment increases the risk of the persistence of hepatic disease and HCC. Interruption of the drug can lead to re-occurrence of hepatocellular damage and neurological crisis. Increased α-fetoprotein and new hypoechoic nodule formation are the warning signs for HCC.
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Affiliation(s)
- A Cigdem Aktuglu Zeybek
- Department of Pediatrics, Division of Nutrition and Metabolism, Istanbul University, Istanbul, Turkey
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