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Maharshi S, Sharma BC. Prophylaxis of hepatic encephalopathy: current and future drug targets. Hepatol Int 2024:10.1007/s12072-024-10647-9. [PMID: 38492132 DOI: 10.1007/s12072-024-10647-9] [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: 09/21/2023] [Accepted: 01/18/2024] [Indexed: 03/18/2024]
Abstract
Hepatic encephalopathy is described by a broad spectrum of neurological and psychiatric aberrations resulting due to advanced liver dysfunction. It is a neurological disorder due to hepatic insufficiency and/or portosystemic shunts. Its clinical presentation includes neuropsychiatric dysfunction ranging from subclinical changes to comatose state. It is a sign of poor prognosis in cirrhotics with a high 1-year mortality. Each episode of hepatic encephalopathy leads to high hospitalization rate, poor prognosis and raised burden of healthcare. Primary prophylaxis is prevention of initial occurrence and secondary prophylaxis is prevention of reappearance of hepatic encephalopathy in subjects who had prior history. Early detection and management of triggers is very important in the treatment of hepatic encephalopathy. The initial choice of treatment is still lactulose, as it is effective in minimal, overt, and recurrent hepatic encephalopathy. Rifaximin is equally effective as lactulose in managing hepatic encephalopathy and is better tolerated. Branch chain amino acids are beneficial in subjects who are protein intolerant. L-ornithine L-aspartate and probiotics are also useful in the management of hepatic encephalopathy. Rifaximin along with lactulose is effective in managing overt and recurrent hepatic encephalopathy. Large portosystemic shunts embolization and liver transplant is efficacious in certain group of patients. Nutritional therapy and fecal microbiota transplantation are newer therapies for hepatic encephalopathy but the evidences are limited, more research is required to prove their efficacy. Involvement of hospital pharmacists, telemedicine, and providing education are also beneficial in managing hepatic encephalopathy.
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Affiliation(s)
- Sudhir Maharshi
- Department of Gastroenterology, SMS Medical College and Hospitals, Jaipur, India
| | - Barjesh Chander Sharma
- Department of Gastroenterology, G.B. Pant Hospital, Room No. 201, Academic Block, New Delhi, 110002, India.
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2
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Yeap JW, Ali IAH, Ibrahim B, Tan ML. Chronic obstructive pulmonary disease and emerging ER stress-related therapeutic targets. Pulm Pharmacol Ther 2023; 81:102218. [PMID: 37201652 DOI: 10.1016/j.pupt.2023.102218] [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: 01/27/2023] [Accepted: 05/05/2023] [Indexed: 05/20/2023]
Abstract
COPD pathogenesis is frequently associated with endoplasmic reticulum stress (ER stress) progression. Targeting the major unfolded protein response (UPR) branches in the ER stress pathway may provide pharmacotherapeutic selection strategies for treating COPD and enable relief from its symptoms. In this study, we aimed to systematically review the potential role of the ER stress inhibitors of major UPR branches (IRE1, PERK, and ATF6) in COPD-related studies and determine the current stage of knowledge in this field. The systematic review was carried out adhering to the PRISMA checklist based on published studies obtained from specific keyword searches of three databases, namely PubMed, ScienceDirect and Springer Database. The search was limited to the year 2000-2022 which includes all in vitro studies, in vivo studies and clinical trials related to the application of ER stress inhibitors toward COPD-induced models and disease. The risk of bias was evaluated using the QUIN, SYRCLE, revised Cochrane risk of bias tool for randomized trials (RoB 2.0) and NIH tool respectively. A total of 7828 articles were screened from three databases and a final total of 37 studies were included in the review. The ER stress and UPR pathways are potentially useful to prevent COPD progression and attenuate the exacerbation of COPD and related symptoms. Interestingly, the off-target effects from inhibition of the UPR pathway may be desirable or undesirable depending on context and therapeutic applications. Targeting the UPR pathway could have complex consequences as the production of ER molecules involved in folding may be impaired which could continuously provoke misfolding of proteins. Although several emerging compounds were noted to be potentially useful for targeted therapy against COPD, clinical studies have yet to be thoroughly explored.
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Affiliation(s)
- Jia Wen Yeap
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800, Pulau, Pinang, Malaysia
| | - Irfhan Ali Hyder Ali
- Respiratory Department, Penang General Hospital, Jalan Residensi, 10990, Pulau, Pinang, Malaysia
| | - Baharudin Ibrahim
- Department of Clinical Pharmacy & Pharmacy Practice, Faculty of Pharmacy, Universiti Malaya, 50603, Kuala Lumpur, Malaysia
| | - Mei Lan Tan
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800, Pulau, Pinang, Malaysia; Centre For Global Sustainability Studies (CGSS), Universiti Sains Malaysia, 11800, Pulau, Pinang, Malaysia.
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Martín-Hernández E, Quijada-Fraile P, Correcher P, Meavilla S, Sánchez-Pintos P, de las Heras Montero J, Blasco-Alonso J, Dougherty L, Marquez A, Peña-Quintana L, Cañedo E, García-Jimenez MC, Moreno Lozano PJ, Murray Hurtado M, Camprodon Gómez M, Barrio-Carreras D, de los Santos M, del Toro M, Couce ML, Vitoria Miñana I, Morales Conejo M, Bellusci M. Switching to Glycerol Phenylbutyrate in 48 Patients with Urea Cycle Disorders: Clinical Experience in Spain. J Clin Med 2022; 11:jcm11175045. [PMID: 36078975 PMCID: PMC9457033 DOI: 10.3390/jcm11175045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/23/2022] [Accepted: 08/24/2022] [Indexed: 11/30/2022] Open
Abstract
Background and objectives: Glycerol phenylbutyrate (GPB) has demonstrated safety and efficacy in patients with urea cycle disorders (UCDs) by means of its clinical trial program, but there are limited data in clinical practice. In order to analyze the efficacy and safety of GPB in clinical practice, here we present a national Spanish experience after direct switching from another nitrogen scavenger to GPB. Methods: This observational, retrospective, multicenter study was performed in 48 UCD patients (age 11.7 ± 8.2 years) switching to GPB in 13 centers from nine Spanish regions. Clinical, biochemical, and nutritional data were collected at three different times: prior to GPB introduction, at first follow-up assessment, and after one year of GPB treatment. Number of related adverse effects and hyperammonemic crisis 12 months before and after GPB introduction were recorded. Results: GPB was administered at a 247.8 ± 102.1 mg/kg/day dose, compared to 262.6 ± 126.1 mg/kg/day of previous scavenger (46/48 Na-phenylbutyrate). At first follow-up (79 ± 59 days), a statistically significant reduction in ammonia (from 40.2 ± 17.3 to 32.6 ± 13.9 μmol/L, p < 0.001) and glutamine levels (from 791.4 ± 289.8 to 648.6 ± 247.41 μmol/L, p < 0.001) was observed. After one year of GPB treatment (411 ± 92 days), we observed an improved metabolic control (maintenance of ammonia and glutamine reduction, with improved branched chain amino acids profile), and a reduction in hyperammonemic crisis rate (from 0.3 ± 0.7 to less than 0.1 ± 0.3 crisis/patients/year, p = 0.02) and related adverse effects (RAE, from 0.5 to less than 0.1 RAEs/patients/year p < 0.001). Conclusions: This study demonstrates the safety of direct switching from other nitrogen scavengers to GPB in clinical practice, which improves efficacy, metabolic control, and RAE compared to previous treatments.
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Affiliation(s)
- Elena Martín-Hernández
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) en Enfermedades Metabólicas, Hospital Universitario 12 de Octubre, Instituto de Investigación i+12, CIBERER, 28041 Madrid, Spain
- Correspondence:
| | - Pilar Quijada-Fraile
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) en Enfermedades Metabólicas, Hospital Universitario 12 de Octubre, Instituto de Investigación i+12, CIBERER, 28041 Madrid, Spain
| | - Patricia Correcher
- Centro de Referencia Nacional de Enfermedades Metabólicas (CSUR), Hospital La Fé de Valencia, 46026 Valencia, Spain
| | - Silvia Meavilla
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) de Enfermedades Metabólicas, Hospital San Joan de Deu Barcelona, 08950 Esplugues de Llobregat, Spain
| | - Paula Sánchez-Pintos
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) de Enfermedades Metabólicas, Hospital Clínico Universitario de Santiago de Compostela, IDIS, CIBERER, 15706 Santiago de Compostela, Spain
| | - Javier de las Heras Montero
- Division of Pediatric Metabolism, CIBERER, MetabERN, Cruces University Hospital, University of the Basque Country (UPV/EHU) and Biocruces-Bizkaia Health Research Institute, 48903 Barakaldo, Spain
| | - Javier Blasco-Alonso
- Sección de Gastroenterología y Nutrición Infantil, Unidad de Enfermedades Metabólicas Hereditarias, Grupo IBIMA Multidisciplinar Pediátrico, Hospital Regional Universitario de Málaga, 29010 Málaga, Spain
| | - Lucy Dougherty
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) de Enfermedades Metabólicas, Hospital Vall D’Hebrón, 08035 Barcelona, Spain
| | - Ana Marquez
- Unidad de Gastroenterología y Enfermedades Metabólicas, Hospital de Badajoz, 06002 Badajoz, Spain
| | - Luis Peña-Quintana
- Unidad de Gastroenterología y Nutrición Pediátrica, Complejo Hospitalario Universitario Insular Materno-Infantil de Las Palmas, CIBEROBN, ISCIII, ACIP, Universidad de Las Palmas de Gran Canaria, 35016 Las Palmas de Gran Canaria, Spain
| | - Elvira Cañedo
- Unidad de Gastroenterología y Nutrición, Hospital del Niño Jesús, 28009 Madrid, Spain
| | | | - Pedro Juan Moreno Lozano
- Unidad de Enfermedades Musculares y Metabólicas Hereditarias, Departamento de Medicina Interna, Hospital Clinic, 08036 Barcelona, Spain
| | - Mercedes Murray Hurtado
- Pediatría, Sección de Nutrición y Errores Innatos del Metabolismo, Complejo Hospitalario Universitario de Canarias, 38320 San Cristóbal de La Laguna, Spain
| | - María Camprodon Gómez
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) de Enfermedades Metabólicas, Hospital Vall D’Hebrón, 08035 Barcelona, Spain
| | - Delia Barrio-Carreras
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) en Enfermedades Metabólicas, Hospital Universitario 12 de Octubre, Instituto de Investigación i+12, CIBERER, 28041 Madrid, Spain
| | - Mariela de los Santos
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) de Enfermedades Metabólicas, Hospital San Joan de Deu Barcelona, 08950 Esplugues de Llobregat, Spain
| | - Mireia del Toro
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) de Enfermedades Metabólicas, Hospital Vall D’Hebrón, 08035 Barcelona, Spain
| | - María L. Couce
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) de Enfermedades Metabólicas, Hospital Clínico Universitario de Santiago de Compostela, IDIS, CIBERER, 15706 Santiago de Compostela, Spain
| | - Isidro Vitoria Miñana
- Centro de Referencia Nacional de Enfermedades Metabólicas (CSUR), Hospital La Fé de Valencia, 46026 Valencia, Spain
| | - Montserrat Morales Conejo
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) en Enfermedades Metabólicas, Hospital Universitario 12 de Octubre, Instituto de Investigación i+12, CIBERER, 28041 Madrid, Spain
| | - Marcello Bellusci
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) en Enfermedades Metabólicas, Hospital Universitario 12 de Octubre, Instituto de Investigación i+12, CIBERER, 28041 Madrid, Spain
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Duran I, Zieba J, Csukasi F, Martin JH, Wachtell D, Barad M, Dawson B, Fafilek B, Jacobsen CM, Ambrose CG, Cohn DH, Krejci P, Lee BH, Krakow D. 4-PBA Treatment Improves Bone Phenotypes in the Aga2 Mouse Model of Osteogenesis Imperfecta. J Bone Miner Res 2022; 37:675-686. [PMID: 34997935 PMCID: PMC9018561 DOI: 10.1002/jbmr.4501] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 12/18/2021] [Accepted: 12/21/2021] [Indexed: 12/01/2022]
Abstract
Osteogenesis imperfecta (OI) is a genetically heterogenous disorder most often due to heterozygosity for mutations in the type I procollagen genes, COL1A1 or COL1A2. The disorder is characterized by bone fragility leading to increased fracture incidence and long-bone deformities. Although multiple mechanisms underlie OI, endoplasmic reticulum (ER) stress as a cellular response to defective collagen trafficking is emerging as a contributor to OI pathogenesis. Herein, we used 4-phenylbutiric acid (4-PBA), an established chemical chaperone, to determine if treatment of Aga2+/- mice, a model for moderately severe OI due to a Col1a1 structural mutation, could attenuate the phenotype. In vitro, Aga2+/- osteoblasts show increased protein kinase RNA-like endoplasmic reticulum kinase (PERK) activation protein levels, which improved upon treatment with 4-PBA. The in vivo data demonstrate that a postweaning 5-week 4-PBA treatment increased total body length and weight, decreased fracture incidence, increased femoral bone volume fraction (BV/TV), and increased cortical thickness. These findings were associated with in vivo evidence of decreased bone-derived protein levels of the ER stress markers binding immunoglobulin protein (BiP), CCAAT/-enhancer-binding protein homologous protein (CHOP), and activating transcription factor 4 (ATF4) as well as increased levels of the autophagosome marker light chain 3A/B (LC3A/B). Genetic ablation of CHOP in Aga2+/- mice resulted in increased severity of the Aga2+/- phenotype, suggesting that the reduction in CHOP observed in vitro after treatment is a consequence rather than a cause of reduced ER stress. These findings suggest the potential use of chemical chaperones as an adjunct treatment for forms of OI associated with ER stress. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Ivan Duran
- Department of Orthopaedic Surgery, David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, CA, USA.,Laboratory of Bioengineering and Tissue Regeneration (LABRET), Department of Cell Biology, Genetics and Physiology, University of Málaga, Institute of Biomedical Research in Malaga (IBIMA), Málaga, Spain.,Networking Biomedical Research Center in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Andalusian Centre for Nanomedicine and Biotechnology (BIONAND), Málaga, Spain
| | - Jennifer Zieba
- Department of Orthopaedic Surgery, David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, CA, USA
| | - Fabiana Csukasi
- Department of Orthopaedic Surgery, David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, CA, USA.,Laboratory of Bioengineering and Tissue Regeneration (LABRET), Department of Cell Biology, Genetics and Physiology, University of Málaga, Institute of Biomedical Research in Malaga (IBIMA), Málaga, Spain.,Networking Biomedical Research Center in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Andalusian Centre for Nanomedicine and Biotechnology (BIONAND), Málaga, Spain
| | - Jorge H Martin
- Department of Orthopaedic Surgery, David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, CA, USA
| | - Davis Wachtell
- Department of Orthopaedic Surgery, David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, CA, USA
| | - Maya Barad
- Department of Orthopaedic Surgery, David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, CA, USA
| | - Brian Dawson
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Bohumil Fafilek
- Department of Biology, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - Christina M Jacobsen
- Divisions of Endocrinology and Genetics and Genomics, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Catherine G Ambrose
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Daniel H Cohn
- Department of Orthopaedic Surgery, David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, CA, USA.,Department of Molecular Cell and Developmental Biology, University of California at Los Angeles, Los Angeles, CA, USA
| | - Pavel Krejci
- Department of Biology, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - Brendan H Lee
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Deborah Krakow
- Department of Orthopaedic Surgery, David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, CA, USA.,Department of Human Genetics, David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, CA, USA.,Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, CA, USA.,Department of Pediatrics, David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, CA, USA
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5
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Li H, Wen W, Luo J. Targeting Endoplasmic Reticulum Stress as an Effective Treatment for Alcoholic Pancreatitis. Biomedicines 2022; 10:biomedicines10010108. [PMID: 35052788 PMCID: PMC8773075 DOI: 10.3390/biomedicines10010108] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/28/2021] [Accepted: 12/30/2021] [Indexed: 02/04/2023] Open
Abstract
Pancreatitis and alcoholic pancreatitis are serious health concerns with an urgent need for effective treatment strategies. Alcohol is a known etiological factor for pancreatitis, including acute pancreatitis (AP) and chronic pancreatitis (CP). Excessive alcohol consumption induces many pathological stress responses; of particular note is endoplasmic reticulum (ER) stress and adaptive unfolded protein response (UPR). ER stress results from the accumulation of unfolded/misfolded protein in the ER and is implicated in the pathogenesis of alcoholic pancreatitis. Here, we summarize the possible mechanisms by which ER stress contributes to alcoholic pancreatitis. We also discuss potential approaches targeting ER stress and UPR in developing novel therapeutic strategies for the disease.
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Affiliation(s)
- Hui Li
- Department of Pathology, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA; (H.L.); (W.W.)
| | - Wen Wen
- Department of Pathology, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA; (H.L.); (W.W.)
| | - Jia Luo
- Department of Pathology, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA; (H.L.); (W.W.)
- Iowa City VA Health Care System, Iowa City, IA 52246, USA
- Correspondence: ; Tel.: +1-319-335-2256
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Rajpurohit S, Musunuri B, Basthi Mohan P, Shetty S. Novel Drugs for the Management of Hepatic Encephalopathy: Still a Long Journey to Travel. J Clin Exp Hepatol 2022; 12:1200-1214. [PMID: 35814520 PMCID: PMC9257922 DOI: 10.1016/j.jceh.2022.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/24/2022] [Indexed: 12/12/2022] Open
Abstract
Hepatic encephalopathy (HE) is one of the reversible complications of chronic liver disease, associated with a higher mortality rate. In current clinical practice, treatment with rifaximin and lactulose/lactitol is the first line of treatment in HE. With the advance in pathophysiology, a new class of ammonia lowering drugs has been revealed to overcome the hurdle and disease burden. The mechanism of the novel agents differs significantly and includes the alteration in intestinal microbiota, intestinal endothelial integrity, oxidative stress, inflammatory markers, and modulation of neurotoxins. Most of the trials have reported promising results in the treatment and prevention of HE with fecal microbiota transplantation, albumin, probiotics, flumazenil, polyethylene glycol, AST-120, glycerol phenylbutyrate, nitazoxanide, branched-chain amino acid, naloxone, and acetyl-l-carnitine. However, their clinical use is limited due to the presence of major drawbacks in their study design, sample size, safety profile, bias, and heterogenicity. This study will discuss the novel therapeutic targets for HE in liver cirrhosis patients with supporting clinical trial data.
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Key Words
- ALC, acetyl-L-carnitine
- BCAA, branched-chain amino acid
- BD, twice a day
- BDI, Beck Depression Inventory
- BUN, blood urea nitrogen
- CHESS, Clinical Hepatic Encephalopathy Staging Scale
- CLDQ, Chronic Liver Disease Questionnaire
- ECT, estimated completion time
- EEG, electroencephalogram
- FMT, fecal microbiota transplantation
- GPB, glycerol phenylbutyrate
- HESA, Hepatic Encephalopathy Scoring Algorithm
- HRQOL, health-related quality of life
- IV, intravenous
- MED, Modified Encephalopathy Scale
- MELD, Model for End-stage Liver Disease
- MMSE, Mini-Mental State Examination
- NTZ, nitazoxanide
- Nal, naloxone
- OD, once a day
- ORT, object recognition test
- PEG, polyethylene glycol
- QID, four times a day
- QOL, quality of life
- RBNS, Repeatable Battery for the Assessment of Neuropsychological Status
- RCT, randomized control trial
- RT-qPCR, real-time quantitative polymerase chain reaction
- TID, three times a day
- VSL#3, high concentration probiotic preparations
- hepatic encephalopathy
- liver cirrhosis
- novel drugs
- treatment outcome
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Affiliation(s)
| | | | | | - Shiran Shetty
- Address for correspondence: Shiran Shetty, Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal 576104, Karnataka, India.
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Ficicioglu C, Liu N, Sun Q, Burdett A, Hata A, Porter M, Sutton VR. Perceptions and use of phenylbutyrate metabolite testing in urea cycle disorders: Results of a clinician survey and analysis of a centralized testing database. Mol Genet Metab 2022; 135:35-41. [PMID: 34980542 DOI: 10.1016/j.ymgme.2021.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 11/24/2022]
Abstract
The nitrogen scavengers sodium and glycerol phenylbutyrate (PB), approved for chronic treatment of urea cycle disorders (UCDs), undergo hepatic conversion to phenylacetate (PAA), which conjugates glutamine to form phenylacetylglutamine for urinary nitrogen excretion. Elevated PAA has been associated with reversible neurological toxicity, with symptoms similar to hyperammonemia. Plasma PB metabolite analysis can assess for toxicity and therapeutic drug levels. An online survey was undertaken to assess US clinician perceptions and use of the test in addition to an analysis of centralized US laboratory records. Survey responses from 52 clinicians were analyzed, including 58% who reported using plasma PB metabolite testing. Test users reported managing more UCD patients than nonusers. Users rated the test as "often helpful" for ruling out PAA toxicity (44%), informing PB dosing decisions (42%), and assessing adherence (28%). Test results were reported as most often unremarkable (61%) or suggestive of poor adherence (13%); 46% of users had never encountered results indicative of PAA toxicity. Analyses of laboratory records for 1668 plasma metabolite tests determined that only 5% of samples had plasma PAA-to-phenylacetylglutamine ratios associated with increased risk of PAA toxicity. Nearly half of surveyed clinicians were unsure of metabolite targets; those conducting ad hoc (versus regular) testing were significantly more likely to be unsure of targets. One-fifth of test users identified uncertainties, including questions about test validation, timing, and interpretation. Increased awareness of published PB metabolite data and further clinician education on test interpretation may help to inform the use of metabolite testing to optimize UCD care.
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Affiliation(s)
- Can Ficicioglu
- Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA; Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ning Liu
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Baylor Genetics, Houston, TX, USA
| | - Qin Sun
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Baylor Genetics, Houston, TX, USA
| | | | | | | | - V Reid Sutton
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Baylor Genetics, Houston, TX, USA; Inborn Errors of Metabolism Service, Texas Children's Hospital, Houston, TX, USA.
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8
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Hasan LZ, Wu GY. Novel Agents in the Management of Hepatic Encephalopathy: A Review. J Clin Transl Hepatol 2021; 9:749-759. [PMID: 34722190 PMCID: PMC8516841 DOI: 10.14218/jcth.2021.00102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 05/28/2021] [Accepted: 06/01/2021] [Indexed: 12/15/2022] Open
Abstract
Hepatic encephalopathy is an often devastating complication of chronic liver disease, associated with high mortality and increased burden on patients and healthcare systems. Current agents (such as nonabsorbable disaccharides and oral antibiotics) are often only partially effective and associated with unpleasant side effects. With our improved understanding of the pathophysiology of hepatic encephalopathy, multiple treatment modalities have emerged with promising results when used alone or as an adjunct to standard medications. The mechanisms of these agents vary greatly, and include the manipulation of gut microbial composition, reduction of oxidative stress, inhibition of inflammatory mediators, protection of endothelial integrity, modulation of neurotransmitter release and function, and other novel methods to reduce blood ammonia and neurotoxins. Despite their promising results, the studies assessing these treatment modalities are often limited by study design, sample size, outcome assessment heterogeneity, and paucity of data regarding their safety profiles. In this article, we discuss these novel agents in depth and provide the best evidence supporting their use, along with a critical look at their limitations and future directions.
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Affiliation(s)
- Leen Z. Hasan
- Correspondence to: Leen Z. Hasan, Department of Medicine, Internal Medicine Residency Program, UConn Health, 263 Farmington Avenue, Farmington, CT 06030-1235, USA. ORCID: https://orcid.org/0000-0003-3852-8591. Tel: +1-617-283-6633, Fax: +1-860-679-4613, E-mail: ,
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9
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Ribas GS, Lopes FF, Deon M, Vargas CR. Hyperammonemia in Inherited Metabolic Diseases. Cell Mol Neurobiol 2021; 42:2593-2610. [PMID: 34665389 DOI: 10.1007/s10571-021-01156-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/10/2021] [Indexed: 12/13/2022]
Abstract
Ammonia is a neurotoxic compound which is detoxified through liver enzymes from urea cycle. Several inherited or acquired conditions can elevate ammonia concentrations in blood, causing severe damage to the central nervous system due to the toxic effects exerted by ammonia on the astrocytes. Therefore, hyperammonemic patients present potentially life-threatening neuropsychiatric symptoms, whose severity is related with the hyperammonemia magnitude and duration, as well as the brain maturation stage. Inherited metabolic diseases caused by enzymatic defects that compromise directly or indirectly the urea cycle activity are the main cause of hyperammonemia in the neonatal period. These diseases are mainly represented by the congenital defects of urea cycle, classical organic acidurias, and the defects of mitochondrial fatty acids oxidation, with hyperammonemia being more severe and frequent in the first two groups mentioned. An effective and rapid treatment of hyperammonemia is crucial to prevent irreversible neurological damage and it depends on the understanding of the pathophysiology of the diseases, as well as of the available therapeutic approaches. In this review, the mechanisms underlying the hyperammonemia and neurological dysfunction in urea cycle disorders, organic acidurias, and fatty acids oxidation defects, as well as the therapeutic strategies for the ammonia control will be discussed.
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Affiliation(s)
- Graziela Schmitt Ribas
- Departamento de Análises Clínicas, Faculdade de Farmácia, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil. .,Serviço de Genética Médica, Hospital de Clíınicas de Porto Alegre, Ramiro Barcelos, 2350, Porto Alegre, RS, CEP 90035-003, Brazil.
| | - Franciele Fátima Lopes
- Serviço de Genética Médica, Hospital de Clíınicas de Porto Alegre, Ramiro Barcelos, 2350, Porto Alegre, RS, CEP 90035-003, Brazil
| | - Marion Deon
- Serviço de Genética Médica, Hospital de Clíınicas de Porto Alegre, Ramiro Barcelos, 2350, Porto Alegre, RS, CEP 90035-003, Brazil
| | - Carmen Regla Vargas
- Departamento de Análises Clínicas, Faculdade de Farmácia, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil. .,Serviço de Genética Médica, Hospital de Clíınicas de Porto Alegre, Ramiro Barcelos, 2350, Porto Alegre, RS, CEP 90035-003, Brazil.
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10
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Chen SZ, Ling Y, Yu LX, Song YT, Chen XF, Cao QQ, Yu H, Chen C, Tang JJ, Fan ZC, Miao YS, Dong YP, Tao JY, Monga SPS, Wen W, Wang HY. 4-phenylbutyric acid promotes hepatocellular carcinoma via initiating cancer stem cells through activation of PPAR-α. Clin Transl Med 2021; 11:e379. [PMID: 33931972 PMCID: PMC8087947 DOI: 10.1002/ctm2.379] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 12/12/2022] Open
Abstract
Background and aims 4‐phenylbutyric acid (4‐PBA) is a low molecular weight fatty acid that is used in clinical practice to treat inherited urea cycle disorders. In previous reports, it acted as a chemical chaperone inhibiting endoplasmic reticulum (ER) stress and unfolded protein response signaling. A few studies have suggested its function against hepatic fibrosis in mice models. However, its role in hepatocarcinogenesis remained unknown. Methods 4‐PBA was administered alone or in combination with diethylnitrosamine to investigate its long‐term effect on liver tumorigenesis. The role of 4‐PBA in oncogene‐induced hepatocellular carcinoma (HCC) mice model using sleeping beauty system co‐expressed with hMet and β‐catenin point mutation (S45Y) was also observed. RNA‐seq and PCR array were used to screen the pathways and genes involved. In vitro and in vivo studies were conducted to explore the effect of 4‐PBA on liver and validate the underlying mechanism. Results 4‐PBA alone didn't cause liver tumor in long term. However, it promoted liver tumorigenesis in HCC mice models via initiation of liver cancer stem cells (LCSCs) through Wnt5b‐Fzd5 mediating β‐catenin signaling. Peroxisome proliferator‐activated receptors (PPAR)‐α induced by 4‐PBA was responsible for the activation of β‐catenin signaling. Thus, intervention of PPAR‐α reversed 4‐PBA‐induced initiation of LCSCs and HCC development in vivo. Further study revealed that 4‐PBA could not only upregulate the expression of PPAR‐α transcriptionally but also enhance its stabilization via protecting it from proteolysis. Moreover, high PPAR‐α expression predicted poor prognosis in HCC patients. Conclusions 4‐PBA could upregulate PPAR‐α to initiate LCSCs by activating β‐catenin signaling pathway, promoting HCC at early stage. Therefore, more discretion should be taken to monitor the potential tumor‐promoting effect of 4‐PBA under HCC‐inducing environment.
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Affiliation(s)
- Shu-Zhen Chen
- National Center for Liver Cancer, Second Military Medical University, Shanghai, China.,International Cooperation Laboratory on Signal Transduction, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Yan Ling
- National Center for Liver Cancer, Second Military Medical University, Shanghai, China.,International Cooperation Laboratory on Signal Transduction, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Le-Xing Yu
- National Center for Liver Cancer, Second Military Medical University, Shanghai, China.,International Cooperation Laboratory on Signal Transduction, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Yu-Ting Song
- National Center for Liver Cancer, Second Military Medical University, Shanghai, China.,International Cooperation Laboratory on Signal Transduction, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China.,Model Animal Research Center, Nanjing University, Nanjing, Jiangsu Province, China
| | - Xiao-Fei Chen
- School of Pharmacy, Second Military Medical University, Shanghai, China
| | - Qi-Qi Cao
- National Center for Liver Cancer, Second Military Medical University, Shanghai, China.,International Cooperation Laboratory on Signal Transduction, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Han Yu
- National Center for Liver Cancer, Second Military Medical University, Shanghai, China.,International Cooperation Laboratory on Signal Transduction, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Can Chen
- National Center for Liver Cancer, Second Military Medical University, Shanghai, China.,International Cooperation Laboratory on Signal Transduction, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China.,Fujian Medical University, Fuzhou, Fujian Province, China
| | - Jiao-Jiao Tang
- National Center for Liver Cancer, Second Military Medical University, Shanghai, China.,Cancer Research Center, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui Province, China
| | - Zhe-Cai Fan
- National Center for Liver Cancer, Second Military Medical University, Shanghai, China
| | - Yu-Shan Miao
- National Center for Liver Cancer, Second Military Medical University, Shanghai, China.,International Cooperation Laboratory on Signal Transduction, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Ya-Ping Dong
- National Center for Liver Cancer, Second Military Medical University, Shanghai, China.,International Cooperation Laboratory on Signal Transduction, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China.,Fujian Medical University, Fuzhou, Fujian Province, China
| | - Jun-Yan Tao
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Satdarshan P S Monga
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Wen Wen
- National Center for Liver Cancer, Second Military Medical University, Shanghai, China.,International Cooperation Laboratory on Signal Transduction, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Hong-Yang Wang
- National Center for Liver Cancer, Second Military Medical University, Shanghai, China.,International Cooperation Laboratory on Signal Transduction, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China.,Model Animal Research Center, Nanjing University, Nanjing, Jiangsu Province, China.,State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Fujian Medical University, Fuzhou, Fujian Province, China.,Cancer Research Center, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui Province, China
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11
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Butterworth RF. Ammonia Removal by Metabolic Scavengers for the Prevention and Treatment of Hepatic Encephalopathy in Cirrhosis. Drugs R D 2021; 21:123-132. [PMID: 33890246 PMCID: PMC8206241 DOI: 10.1007/s40268-021-00345-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2021] [Indexed: 12/18/2022] Open
Abstract
Effective lowering of circulating ammonia is the mainstay strategy in the prevention and treatment of hepatic encephalopathy in cirrhosis and there is increasing interest in agents with the metabolic potential for the active removal of ammonia by the liver and skeletal muscle by agents including L-ornithine L-aspartate, branched-chain amino acids, as well as the re-purposing of benzoate and phenylacetate currently employed for the control of hyperammonaemia in congenital urea-cycle enzymopathies. Based upon results of multiple systematic reviews with meta-analyses, L-ornithine L-aspartate demonstrably lowers circulating ammonia in patients with cirrhosis with concomitantly improved mental status. Distinct mechanisms responsible include optimisation of hepatic metabolic pathways for ammonia removal as well as direct hepatoprotective effects involving the release of glutathione and of nitric oxide with beneficial effects on hepatic microcirculation. L-ornithine L-aspartate also prevents cirrhosis-related sarcopenia, leading to increased capacity for ammonia removal by skeletal muscle. Branched-chain amino acids continue to be prescribed as nutritional supplements with the potential to result in improvements in liver function. Sodium benzoate, glycerol phenylbutyrate and an analogous compound L-ornithine phenylacetate were also evaluated. Glycerol phenylbutyrate was the only agent with a beneficial effect on both hyperammonaemia and hepatic encephalopathy. None were superior to lactulose for the lowering of blood ammonia.
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Affiliation(s)
- Roger F Butterworth
- Department of Medicine, University of Montreal, 45143 Cabot Trail, Englishtown, NS, B0C 1H0, Canada.
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12
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Sato T, Ishii T, Kato M, Oyanagi T, Nakatsuka S, Kuroda T, Hasegawa T. Oral sodium phenylbutyrate for hyperammonemia associated with congenital portosystemic shunt: a case report. J Pediatr Endocrinol Metab 2021; 34:407-410. [PMID: 33675205 DOI: 10.1515/jpem-2020-0603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 11/22/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The efficacy of sodium phenylbutyrate (SPB) for hyperammonemia associated with congenital portosystemic shunt (CPSS) remains unknown. We show the effectiveness of oral SPB. CASE PRESENTATION Our patient had CPSS with severe hypoplasia of extrahepatic portal veins. At 9 months of age, to assess the efficacy of oral SPB, we evaluated the 24 h fluctuations of venous ammonia levels. In the first two days without SPB, ammonia levels were above 80 μmol/L for half a day. On the third and fourth days, administration of oral SPB three times a day decreased ammonia to acceptable levels, except at midnight. On the fifth day, another oral SPB administration at 8 pm decreased ammonia at midnight. Low levels of branched-chain amino acids, as well as coagulation disturbances, were observed without apparent symptoms. At 12 months of age, he showed normal psychomotor development. CONCLUSIONS Oral SPB may be effective for hyperammonemia associated with CPSS.
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Affiliation(s)
- Takeshi Sato
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Tomohiro Ishii
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Mototoshi Kato
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Takayuki Oyanagi
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Seishi Nakatsuka
- Department of Diagnostic Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Tatsuo Kuroda
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Tomonobu Hasegawa
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
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13
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Longo N, Diaz GA, Lichter-Konecki U, Schulze A, Inbar-Feigenberg M, Conway RL, Bannick AA, McCandless SE, Zori R, Hainline B, Ah Mew N, Canavan C, Vescio T, Kok T, Porter MH, Berry SA. Glycerol phenylbutyrate efficacy and safety from an open label study in pediatric patients under 2 months of age with urea cycle disorders. Mol Genet Metab 2021; 132:19-26. [PMID: 33388234 PMCID: PMC8655853 DOI: 10.1016/j.ymgme.2020.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/08/2020] [Accepted: 12/09/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND/AIMS Neonatal onset Urea cycle disorders (UCDs) can be life threatening with severe hyperammonemia and poor neurological outcomes. Glycerol phenylbutyrate (GPB) is safe and effective in reducing ammonia levels in patients with UCD above 2 months of age. This study assesses safety, ammonia control and pharmacokinetics (PK) of GPB in UCD patients below 2 months of age. METHODS This was an open-label study in UCD patients aged 0 - 2 months, consisting of an initiation/transition period (1 - 4 days) to GPB, followed by a safety extension period (6 months to 2 years). Patients presenting with a hyperammonemic crisis (HAC) did not initiate GPB until blood ammonia levels decreased to below 100 µmol/L while receiving sodium phenylacetate/sodium benzoate and/or hemodialysis. Ammonia levels, PK analytes and safety were evaluated during transition and monthly during the safety extension for 6 months and every 3 months thereafter. RESULTS All 16 patients with UCD (median age 0.48 months, range 0.1 to 2.0 months) successfully transitioned to GPB within 3 days. Average plasma ammonia level excluding HAC was 94.3 µmol/L at baseline and 50.4 µmol/L at the end of the transition period (p = 0.21). No patient had a HAC during the transition period. During the safety extension, the majority of patients had controlled ammonia levels, with mean plasma ammonia levels lower during GPB treatment than baseline. Mean glutamine levels remained within normal limits throughout the study. PK analyses indicate that UCD patients <2 months are able to hydrolyze GPB with subsequent absorption of phenylbutyric acid (PBA), metabolism to phenylacetic acid (PAA) and conjugation with glutamine. Plasma concentrations of PBA, PAA, and phenylacetylglutamine (PAGN) were stable during the safety extension phase and mean plasma phenylacetic acid: phenylacetylglutamine ratio remained below 2.5 suggesting no accumulation of GPB. All patients reported at least 1 treatment emergent adverse event with gastroesophageal reflux disease, vomiting, hyperammonemia, diaper dermatitis (37.5% each), diarrhea, upper respiratory tract infection and rash (31.3% each) being the most frequently reported. CONCLUSIONS This study supports safety and efficacy of GPB in UCD patients aged 0 -2 months who cannot be managed by dietary protein restriction and/or amino acid supplementation alone. GPB undergoes intestinal hydrolysis with no accumulation in this population.
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Affiliation(s)
| | - George A Diaz
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Andreas Schulze
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Shawn E McCandless
- University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
| | | | - Bryan Hainline
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | | | | | - Teresa Kok
- Horizon Therapeutics plc, Deerfield, IL, USA.
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14
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Abstract
Despite widespread use of lactulose and rifaximin for the treatment of hepatic encephalopathy, this complication of advanced liver disease remains a major burden on the health care system in the United States and continues to predispose to high morbidity and mortality. Several agents have surfaced over recent years with promise to treat hepatic encephalopathy and mitigate the cognitive impairment associated with this disease process. The purpose of this article is to highlight the leading emerging therapies in hepatic encephalopathy as well as their therapeutic targets.
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15
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Hu Y, Yang W, Xie L, Liu T, Liu H, Liu B. Endoplasmic reticulum stress and pulmonary hypertension. Pulm Circ 2020; 10:2045894019900121. [PMID: 32110387 PMCID: PMC7000863 DOI: 10.1177/2045894019900121] [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] [Received: 09/24/2019] [Accepted: 12/19/2019] [Indexed: 12/14/2022] Open
Abstract
Pulmonary hypertension is a fatal disease of which pulmonary vasculopathy is the main pathological feature resulting in the mean pulmonary arterial pressure higher than 25 mmHg. Moreover, pulmonary hypertension remains a tough problem with unclear molecular mechanisms. There have been dozens of studies about endoplasmic reticulum stress during the onset of pulmonary hypertension in patients, suggesting that endoplasmic reticulum stress may have a critical effect on the pathogenesis of pulmonary hypertension. The review aims to summarize the rationale to elucidate the role of endoplasmic reticulum stress in pulmonary hypertension. Started by reviewing the mechanisms responsible for the unfolded protein response following endoplasmic reticulum stress, the potential link between endoplasmic reticulum stress and pulmonary hypertension were introduced, and the contributions of endoplasmic reticulum stress to different vascular cells, mitochondria, and inflammation were described, and finally the potential therapies of attenuating endoplasmic reticulum stress for pulmonary hypertension were discussed.
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Affiliation(s)
- Yanan Hu
- Department of Pediatrics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Wenhao Yang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China.,The Vascular Remodeling and Developmental Defects Research Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Liang Xie
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China.,The Vascular Remodeling and Developmental Defects Research Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Tao Liu
- Department of Pediatrics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Hanmin Liu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China.,The Vascular Remodeling and Developmental Defects Research Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Bin Liu
- Department of Pediatrics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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16
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Häberle J, Burlina A, Chakrapani A, Dixon M, Karall D, Lindner M, Mandel H, Martinelli D, Pintos-Morell G, Santer R, Skouma A, Servais A, Tal G, Rubio V, Huemer M, Dionisi-Vici C. Suggested guidelines for the diagnosis and management of urea cycle disorders: First revision. J Inherit Metab Dis 2019; 42:1192-1230. [PMID: 30982989 DOI: 10.1002/jimd.12100] [Citation(s) in RCA: 236] [Impact Index Per Article: 47.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 04/04/2019] [Accepted: 04/08/2019] [Indexed: 02/06/2023]
Abstract
In 2012, we published guidelines summarizing and evaluating late 2011 evidence for diagnosis and therapy of urea cycle disorders (UCDs). With 1:35 000 estimated incidence, UCDs cause hyperammonemia of neonatal (~50%) or late onset that can lead to intellectual disability or death, even while effective therapies do exist. In the 7 years that have elapsed since the first guideline was published, abundant novel information has accumulated, experience on newborn screening for some UCDs has widened, a novel hyperammonemia-causing genetic disorder has been reported, glycerol phenylbutyrate has been introduced as a treatment, and novel promising therapeutic avenues (including gene therapy) have been opened. Several factors including the impact of the first edition of these guidelines (frequently read and quoted) may have increased awareness among health professionals and patient families. However, under-recognition and delayed diagnosis of UCDs still appear widespread. It was therefore necessary to revise the original guidelines to ensure an up-to-date frame of reference for professionals and patients as well as for awareness campaigns. This was accomplished by keeping the original spirit of providing a trans-European consensus based on robust evidence (scored with GRADE methodology), involving professionals on UCDs from nine countries in preparing this consensus. We believe this revised guideline, which has been reviewed by several societies that are involved in the management of UCDs, will have a positive impact on the outcomes of patients by establishing common standards, and spreading and harmonizing good practices. It may also promote the identification of knowledge voids to be filled by future research.
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Affiliation(s)
- Johannes Häberle
- University Children's Hospital Zurich and Children's Research Centre, Zurich, Switzerland
| | - Alberto Burlina
- Division of Inborn Metabolic Disease, Department of Pediatrics, University Hospital Padua, Padova, Italy
| | - Anupam Chakrapani
- Department of Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Marjorie Dixon
- Dietetics, Great Ormond Street Hospital for Children, NHS Trust, London, UK
| | - Daniela Karall
- Clinic for Pediatrics, Division of Inherited Metabolic Disorders, Medical University of Innsbruck, Innsbruck, Austria
| | - Martin Lindner
- University Children's Hospital, Frankfurt am Main, Germany
| | - Hanna Mandel
- Institute of Human Genetics and metabolic disorders, Western Galilee Medical Center, Nahariya, Israel
| | - Diego Martinelli
- Division of Metabolism, Bambino Gesù Children's Hospital, Rome, Italy
| | - Guillem Pintos-Morell
- Centre for Rare Diseases, University Hospital Vall d'Hebron, Barcelona, Spain
- CIBERER_GCV08, Research Institute IGTP, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - René Santer
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anastasia Skouma
- Institute of Child Health, Agia Sofia Children's Hospital, Athens, Greece
| | - Aude Servais
- Service de Néphrologie et maladies métaboliques adulte Hôpital Necker 149, Paris, France
| | - Galit Tal
- The Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Vicente Rubio
- Instituto de Biomedicina de Valencia (IBV-CSIC), Centro de Investigación Biomédica en Red para Enfermedades Raras (CIBERER), Valencia, Spain
| | - Martina Huemer
- University Children's Hospital Zurich and Children's Research Centre, Zurich, Switzerland
- Department of Paediatrics, Landeskrankenhaus Bregenz, Bregenz, Austria
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17
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4-Phenylbutyric Acid Reduces Endoplasmic Reticulum Stress in Chondrocytes That Is Caused by Loss of the Protein Disulfide Isomerase ERp57. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2019; 2019:6404035. [PMID: 31781343 PMCID: PMC6875354 DOI: 10.1155/2019/6404035] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 09/01/2019] [Indexed: 01/30/2023]
Abstract
Objective The integrity of cartilage depends on the correct synthesis of extracellular matrix (ECM) components. In case of insufficient folding of proteins in the endoplasmic reticulum (ER) of chondrocytes, ECM proteins aggregate, ER stress evolves, and the unfolded protein response (UPR) is initiated. By this mechanism, chondrocytes relieve the stress condition or initiate cell death by apoptosis. Especially persistent ER stress has emerged as a pathogenic mechanism in cartilage diseases, such as chondrodysplasias and osteoarthritis. As pharmacological intervention is not available yet, it is of great interest to understand cartilage ER stress in detail and to develop therapeutics to intervene. Methods ERp57-deficient chondrocytes were generated by CRISPR/Cas9-induced KO. ER stress and autophagy were studied on mRNA and protein level as well as by transmission electron microscopy (TEM) in chondrocyte micromass or cartilage explant cultures of ERp57 KO mice. Thapsigargin (Tg), an inhibitor of the ER-residing Ca2+-ATPase, and 4-Phenylbutyric acid (4-PBA), a small molecular chemical chaperone, were applied to induce or inhibit ER stress. Results Our data reveal that the loss of the protein disulfide isomerase ERp57 is sufficient to induce ER stress in chondrocytes. 4-PBA efficiently diffuses into cartilage explant cultures and diminishes excessive ER stress in chondrocytes dose dependently, no matter if it is induced by ERp57 KO or stimulation with Tg. Conclusion ER-stress-related diseases have different sources; therefore, various targets for therapeutic treatment exist. In the future, 4-PBA may be used alone or in combination with other drugs for the treatment of ER-stress-related skeletal disorders in patients.
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18
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Rahtes A, Pradhan K, Sarma M, Xie D, Lu C, Li L. Phenylbutyrate facilitates homeostasis of non-resolving inflammatory macrophages. Innate Immun 2019; 26:62-72. [PMID: 31604378 PMCID: PMC6974874 DOI: 10.1177/1753425919879503] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Non-resolving inflammatory monocytes/macrophages are critically involved in the
pathogenesis of chronic inflammatory diseases. However, mechanisms of macrophage
polarization are not well understood, thus hindering the development of
effective strategies to promote inflammation resolution. In this study, we
report that macrophages polarized by subclinical super-low dose LPS
preferentially expressed pro-inflammatory mediators such as
ccl2 (which encodes the protein monocyte chemo attractant
protein-1) with reduced expression of anti-inflammatory/homeostatic mediators
such as slc40a1 (which encodes the protein ferroportin-1). We
observed significantly elevated levels of the autophagy-associated and
pro-inflammatory protein p62 in polarized macrophages, closely correlated with
the inflammatory activation of ccl2 gene expression. In
contrast, we noted a significant increase of ubiquitinated/inactive
nuclear-erythroid-related factor 2 (NRF2), consistent with reduced
slc40a1 gene expression in polarized macrophages. Addition
of the homeostatic restorative agent phenylbutyrate (4-PBA) effectively reduced
cellular levels of p62 as well as ccl2 gene induction by
super-low dose LPS. On the other hand, application of 4-PBA also blocked the
accumulation of ubiquitinated NRF2 and restored anti-inflammatory
slc40a1 gene expression in macrophages. Together, our study
provides novel insights with regard to macrophage polarization and reveals 4-PBA
as a promising molecule in restoring macrophage homeostasis.
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Affiliation(s)
| | - Kisha Pradhan
- Department of Biological Sciences, Virginia Tech, USA
| | - Mimosa Sarma
- Department of Chemical Engineering, Virginia Tech, USA
| | - David Xie
- Department of Biomedical Sciences and Pathobiology, Virginia Tech, USA
| | - Chang Lu
- Department of Chemical Engineering, Virginia Tech, USA
| | - Liwu Li
- Department of Biological Sciences, Virginia Tech, USA
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19
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Enns GM, Porter MH, Francis-Sedlak M, Burdett A, Vockley J. Perspectives on urea cycle disorder management: Results of a clinician survey. Mol Genet Metab 2019; 128:102-108. [PMID: 31377149 DOI: 10.1016/j.ymgme.2019.07.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/12/2019] [Accepted: 07/16/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND/AIMS Urea cycle disorders (UCDs) are rare inborn errors of urea synthesis. US and European consensus statements on the diagnosis and treatment of UCDs were last published in 2001 and 2019, respectively. Recommendations are based primarily on case reports and expert opinion and there is limited agreement or consistency related to long-term management approaches. A clinician survey was conducted to assess current real-world practices and perspectives on challenges and unmet needs. METHODS A 14-item multiple-choice survey was administered to physicians in 2017. Clinicians who reported actively managing at least 1 patient with UCD were eligible to participate. Descriptive statistics were calculated for each survey item (frequencies for categorical variables; means, standard deviations, medians, and ranges for continuous variables). RESULTS Sixty-six US clinicians completed the survey (65 geneticists; 1 pediatric neurologist). Over 90% of responders agreed or strongly agreed that even modest elevations in ammonia could cause physiological and functional brain damage; >80% of respondents agreed that asymptomatic UCD patients are at risk of brain damage over time due to mild/subclinical elevations in ammonia. Eighty-six percent of clinicians agreed or strongly agreed with recommending genetic testing for female relatives when a patient is diagnosed with ornithine transcarbamylase deficiency. Ninety-four percent of respondents agreed that patients have better disease control when they are more adherent to their UCD therapy. Nearly 90% indicated that clinicians and patients would benefit from updated UCD management guidance. More than half (53%) of respondents rated the symptoms of UCDs as extremely or very burdensome to the everyday lives of patients and their families; only 8% rated UCD symptoms as slightly or not at all burdensome. The majority of clinicians agreed (48%) or strongly agreed (32%) that caring for a child or family member with a UCD has a negative impact on the quality of life and/or health of family members/guardians (e.g. stress, relationships, ability to work). CONCLUSIONS This self-reported survey suggests a need for updated and expanded clinical guidance on the long-term treatment and management of UCD patients.
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Affiliation(s)
- Gregory M Enns
- Stanford University, School of Medicine, Stanford, CA, USA.
| | | | | | | | - Jerry Vockley
- University of Pittsburgh, School of Medicine, Graduate School of Public Health, Pittsburgh, PA, USA
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20
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Li H, Wen W, Xu H, Wu H, Xu M, Frank JA, Luo J. 4-Phenylbutyric Acid Protects Against Ethanol-Induced Damage in the Developing Mouse Brain. Alcohol Clin Exp Res 2018; 43:69-78. [PMID: 30403409 DOI: 10.1111/acer.13918] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 10/27/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Ethanol (EtOH) exposure during pregnancy may result in fetal alcohol spectrum disorders (FASD). One of the most deleterious consequences of EtOH exposure is neuronal loss in the developing brain. Previously, we showed that EtOH exposure induced neuroapoptosis in the brain of postnatal day 4 (PD4) mice but not PD12 mice. This differential susceptibility may result from an insufficient cellular stress response system such as unfolded protein response (also known as endoplasmic reticulum [ER] stress) in PD4 mice. In this study, we compared the effect of EtOH on ER stress in PD4 and PD12 mice and determined whether the inhibition of ER stress could protect the developing brain against EtOH damage. METHODS We used a third-trimester equivalent mouse model of FASD. PD4 and PD12 C57BL/6 mice were subcutaneously injected with saline (control), EtOH, EtOH plus 4-phenylbutyric acid (4-PBA), a chemical chaperone known as ER stress inhibitor, and 4-PBA alone. The expression of apoptosis marker, ER stress markers, and markers for glial cell activation was examined in the cerebral cortex. RESULTS EtOH induced neuroapoptosis and increased the expression of ER stress markers, such as activating transcription factor 6, 78-kDa glucose-regulated protein, inositol-requiring enzyme 1α, mesencephalic astrocyte-derived neurotrophic factor, and caspase-12 in PD4 but not PD12 mice. EtOH exposure also activated microglia and astrocytes. Interestingly, treatment with 4-PBA attenuated EtOH-induced neuroapoptosis. Moreover, 4-PBA inhibited the expression of the aforementioned ER stress markers and EtOH-induced glial activation in PD4 mice. CONCLUSIONS ER stress plays an important role in EtOH-induced damage to the developing brain. Inhibition of ER stress is neuroprotective and may provide a new therapeutic strategy for treating FASD.
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Affiliation(s)
- Hui Li
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Wen Wen
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Hong Xu
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Huaxun Wu
- Institute of Clinical Pharmacology, Key Laboratory of Anti-Inflammatory and Immune Medicine, Anhui Medical University, Hefei, China
| | - Mei Xu
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Jacqueline A Frank
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Jia Luo
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, Kentucky.,Lexington VA Health Care System, Research & Development, Lexington, Kentucky
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21
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Hong YP, Deng WH, Guo WY, Shi Q, Zhao L, You YD, Mei FC, Zhou Y, Wang CY, Chen C, Yu J, Wang WX. Inhibition of endoplasmic reticulum stress by 4-phenylbutyric acid prevents vital organ injury in rat acute pancreatitis. Am J Physiol Gastrointest Liver Physiol 2018; 315:G838-G847. [PMID: 30138574 DOI: 10.1152/ajpgi.00102.2018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
This study was conducted to investigate the effect of 4-phenylbutyric acid (4-PBA) on vital organ injury following sodium taurocholate-induced acute pancreatitis (AP) in rats and the pertinent mechanism. The serum biochemical indicators and key inflammatory cytokines, histopathological damage and apoptosis of vital organs in rat AP, were evaluated in the presence or absence of 4-PBA. Moreover, mRNA and protein levels of endoplasmic reticulum stress (ERS) markers were assessed. 4-PBA significantly attenuated the structural and functional damage of vital organs, including serum pancreatic enzymes, hepatic enzymes, creatinine, and urea. The morphological changes and infiltration of neutrophils and macrophages were reduced as well. These effects were accompanied by decreased serum levels of proinflammatory TNF-α and IL-1β. Furthermore, 4-PBA diminished the expression of ERS markers (glucose-regulated protein 78, CCAAT/enhancer-binding protein homologous protein, protein kinase R-like ER kinase, activated transcription factor 6, and type-1 inositol requiring enzyme) in vital organs of AP rats. 4-PBA also reduced AP-induced apoptosis in lung, liver, and kidney tissues as shown by TUNEL assay. The present study demonstrated that 4-PBA protected pancreas, lung, liver, and kidney from injury in rat AP by regulating ERS and mitigating inflammatory response to restrain cell death and further suggested that 4-PBA may have potential therapeutic implications in the disease. NEW & NOTEWORTHY In this study, we suggest that endoplasmic reticulum stress (ERS) is an important player in the development of acute pancreatitis-induced multiorgan injury, providing additional evidence for the proinflammatory role of ERS. Because 4-phenylbutyric acid has been suggested to inhibit ERS in many pathological conditions, it is possible that this effect can be involved in alleviating inflammatory response and cell death to ameliorate vital organ damage following acute pancreatitis induced by sodium taurocholate in rats.
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Affiliation(s)
- Yu-Pu Hong
- Department of General Surgery, Renmin Hospital of Wuhan University , Wuhan, Hubei , China
| | - Wen-Hong Deng
- Department of General Surgery, Renmin Hospital of Wuhan University , Wuhan, Hubei , China
| | - Wen-Yi Guo
- Department of General Surgery, Renmin Hospital of Wuhan University , Wuhan, Hubei , China
| | - Qiao Shi
- Department of Pancreatic Surgery, Renmin Hospital of Wuhan University , Wuhan, Hubei , China
| | - Liang Zhao
- Department of General Surgery, Renmin Hospital of Wuhan University , Wuhan, Hubei , China.,Key Laboratory of Hubei Province for Digestive System Disease , Wuhan, Hubei , China
| | - Yun-Dong You
- Department of General Surgery, Renmin Hospital of Wuhan University , Wuhan, Hubei , China
| | - Fang-Chao Mei
- Department of General Surgery, Renmin Hospital of Wuhan University , Wuhan, Hubei , China.,Key Laboratory of Hubei Province for Digestive System Disease , Wuhan, Hubei , China
| | - Yu Zhou
- Department of General Surgery, Renmin Hospital of Wuhan University , Wuhan, Hubei , China.,Central Laboratory, Renmin Hospital of Wuhan University , Wuhan, Hubei , China
| | - Chen-Yang Wang
- Department of General Surgery, Renmin Hospital of Wuhan University , Wuhan, Hubei , China
| | - Chen Chen
- Department of General Surgery, Renmin Hospital of Wuhan University , Wuhan, Hubei , China
| | - Jia Yu
- Department of General Surgery, Renmin Hospital of Wuhan University , Wuhan, Hubei , China
| | - Wei-Xing Wang
- Department of General Surgery, Renmin Hospital of Wuhan University , Wuhan, Hubei , China
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Hoshina C, Omura T, Okuda K, Tanaka H, Asari M, Isozaki S, Horioka K, Yamada H, Doi H, Shiono H, Matsubara K, Shimizu K. Paraquat toxicity is attenuated by 4-phenylbutyrate-induced phosphorylation of ERK2 via PI3K in A549 cells. Biochem Biophys Res Commun 2018; 503:809-814. [DOI: 10.1016/j.bbrc.2018.06.080] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 06/15/2018] [Indexed: 02/01/2023]
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23
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Baumann J, Kokabee M, Wong J, Balasubramaniyam R, Sun Y, Conklin DS. Global metabolite profiling analysis of lipotoxicity in HER2/neu-positive breast cancer cells. Oncotarget 2018; 9:27133-27150. [PMID: 29930756 PMCID: PMC6007458 DOI: 10.18632/oncotarget.25500] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 05/10/2018] [Indexed: 12/12/2022] Open
Abstract
Recent work has shown that HER2/neu-positive breast cancer cells rely on a unique Warburg-like metabolism for survival and aggressive behavior. These cells are dependent on fatty acid (FA) synthesis, show markedly increased levels of stored fats and disruption of the synthetic process results in apoptosis. In this study, we used global metabolite profiling and a multi-omics network analysis approach to model the metabolic changes in this physiology under palmitate-supplemented growth conditions to gain insights into the molecular mechanism and its relevance to disease prevention and treatment. Computational analyses were used to define pathway enrichment based on the dataset of significantly altered metabolites and to integrate metabolomics and transcriptomics data in a multi-omics network analysis. Network-predicted changes and functional relationships were tested with cell assays in vitro. Palmitate-supplemented growth conditions induce distinct metabolic alterations. Growth of HER2-normal MCF7 cells is unaffected under these conditions whereas HER2/neu-positive cells display unchanged neutral lipid content, AMPK activation, inhibition of fatty acid synthesis and significantly altered glutamine, glucose and serine/glycine metabolism. The predominant upregulated lipid species is the novel bioactive lipid N-palmitoylglycine, which is non-toxic to these cells. Limiting the availability of glutamine significantly ameliorates the lipotoxic effects of palmitate, reduces CHOP and XBP1(s) induction and restores the expression levels of HER2 and HER3. The study shows that HER2/neu-positive breast cancer cells change their metabolic phenotype in the presence of palmitate. Palmitate induces AMPK activation and inhibition of fatty acid synthesis that feeds back into glycolysis as well as anaplerotic glutamine metabolism.
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Affiliation(s)
- Jan Baumann
- Cancer Research Center, Department of Biomedical Sciences, State University of New York, University at Albany, Rensselaer, NY 12144, USA
| | - Mostafa Kokabee
- Cancer Research Center, Department of Biomedical Sciences, State University of New York, University at Albany, Rensselaer, NY 12144, USA
| | - Jason Wong
- Cancer Research Center, Department of Biomedical Sciences, State University of New York, University at Albany, Rensselaer, NY 12144, USA
| | - Rakshika Balasubramaniyam
- Cancer Research Center, Department of Biomedical Sciences, State University of New York, University at Albany, Rensselaer, NY 12144, USA
| | - Yan Sun
- Cancer Research Center, Department of Biomedical Sciences, State University of New York, University at Albany, Rensselaer, NY 12144, USA
| | - Douglas S Conklin
- Cancer Research Center, Department of Biomedical Sciences, State University of New York, University at Albany, Rensselaer, NY 12144, USA
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24
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Gambello MJ, Li H. Current strategies for the treatment of inborn errors of metabolism. J Genet Genomics 2018; 45:61-70. [PMID: 29500085 DOI: 10.1016/j.jgg.2018.02.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 11/14/2017] [Accepted: 02/11/2018] [Indexed: 12/23/2022]
Abstract
Inborn errors of metabolism (IEMs) are a large group of inherited disorders characterized by disruption of metabolic pathways due to deficient enzymes, cofactors, or transporters. The rapid advances in the understanding of the molecular pathophysiology of many IEMs, have led to significant progress in the development of many new treatments. The institution and continued expansion of newborn screening provide the opportunity for early treatment, leading to reduced morbidity and mortality. This review provides an overview of the diverse therapeutic approaches and recent advances in the treatment of IEMs that focus on the basic principles of reducing substrate accumulation, replacing or enhancing absent or reduced enzyme or cofactor, and supplementing product deficiency. In addition, the challenges and obstacles of current treatment modalities and future treatment perspectives are reviewed and discussed.
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Affiliation(s)
- Michael J Gambello
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Hong Li
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA 30322, USA.
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25
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Longo N, Holt RJ. Glycerol phenylbutyrate for the maintenance treatment of patients with deficiencies in enzymes of the urea cycle. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1405807] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Nicola Longo
- Division of Medical Genetics, University of Utah, Salt Lake City, UT, USA
| | - Robert J. Holt
- Medical Affairs, Horizon Pharma, Lake Forest, IL, USA
- Department of Pharmacy Practice, University of Illinois, Chicago, IL, USA
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26
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Jiang Y, Almannai M, Sutton VR, Sun Q, Elsea SH. Quantitation of phenylbutyrate metabolites by UPLC-MS/MS demonstrates inverse correlation of phenylacetate:phenylacetylglutamine ratio with plasma glutamine levels. Mol Genet Metab 2017; 122:39-45. [PMID: 28888854 DOI: 10.1016/j.ymgme.2017.08.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 08/27/2017] [Accepted: 08/27/2017] [Indexed: 12/31/2022]
Abstract
Urea cycle disorders (UCDs) are genetic conditions characterized by nitrogen accumulation in the form of ammonia and caused by defects in the enzymes required to convert ammonia to urea for excretion. UCDs include a spectrum of enzyme deficiencies, namely n-acetylglutamate synthase deficiency (NAGS), carbamoyl phosphate synthetase I deficiency (CPS1), ornithine transcarbamylase deficiency (OTC), argininosuccinate lyase deficiency (ASL), citrullinemia type I (ASS1), and argininemia (ARG). Currently, sodium phenylbutyrate and glycerol phenylbutyrate are primary medications used to treat patients with UCDs, and long-term monitoring of these compounds is critical for preventing drug toxic levels. Therefore, a fast and simple ultra-performance liquid chromatography (UPLC-MS/MS) method was developed and validated for quantification of phenylbutyrate (PB), phenylacetate (PA), and phenylacetylglutamine (PAG) in plasma and urine. The separation of all three analytes was achieved in 2min, and the limits of detection were <0.04μg/ml. Intra-precision and inter-precision were <8.5% and 4% at two quality control concentrations, respectively. Average recoveries for all compounds ranged from 100% to 106%. With the developed assay, a strong correlation between PA and the PA/PAG ratio and an inverse correlation between PA/PAG ratio and plasma glutamine were observed in 35 patients with confirmed UCDs. Moreover, all individuals with a ratio ≥0.6 had plasma glutamine levels<1000μmol/l. Our data suggest that a PA/PAG ratio in the range of 0.6-1.5 will result in a plasma glutamine level<1000μmol/l without reaching toxic levels of PA.
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Affiliation(s)
- Yi Jiang
- Division of Biochemical Genetics, Baylor Genetics Laboratories, Houston, TX, United States
| | - Mohammed Almannai
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, United States
| | - V Reid Sutton
- Division of Biochemical Genetics, Baylor Genetics Laboratories, Houston, TX, United States; Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, United States
| | - Qin Sun
- Division of Biochemical Genetics, Baylor Genetics Laboratories, Houston, TX, United States; Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, United States
| | - Sarah H Elsea
- Division of Biochemical Genetics, Baylor Genetics Laboratories, Houston, TX, United States; Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, United States.
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27
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Khan S, Komarya SK, Jena G. Phenylbutyrate and β-cell function: contribution of histone deacetylases and ER stress inhibition. Epigenomics 2017; 9:711-720. [PMID: 28470097 DOI: 10.2217/epi-2016-0160] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Incidences of diabetes are increasing globally due to involvement of genetic and epigenetic factors. Phenylbutyrate (PBA) is a US FDA approved drug for treatment of urea cycle disorder in children. PBA reduces endoplasmic reticulum (ER) stress and is proven as a potent histone deacetylases (HDACs) inhibitor. Chronic ER stress results in unfolding protein response, which triggers apoptosis. Abnormal ER homoeostasis is responsible for defective processing of several genes/proteins and contributes to β-cell death/failure. Accumulated evidences indicated that HDACs modulate key biochemical pathways and HDAC inhibitors improve β-cell function and insulin resistance by modulating multiple targets. This review highlights the role of PBA on β-cell functions, insulin resistance for possible treatment of diabetes through inhibition of ER stress and HDACs.
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Affiliation(s)
- Sabbir Khan
- Facility for Risk Assessment & Intervention Studies, Department of Pharmacology & Toxicology, National Institute of Pharmaceutical Education & Research, Sector-67, SAS Nagar, Punjab-160062, India
| | - Sandeep K Komarya
- Facility for Risk Assessment & Intervention Studies, Department of Pharmacology & Toxicology, National Institute of Pharmaceutical Education & Research, Sector-67, SAS Nagar, Punjab-160062, India
| | - Gopabandhu Jena
- Facility for Risk Assessment & Intervention Studies, Department of Pharmacology & Toxicology, National Institute of Pharmaceutical Education & Research, Sector-67, SAS Nagar, Punjab-160062, India
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28
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Sodium 4-phenylbutyric acid prevents murine acetaminophen hepatotoxicity by minimizing endoplasmic reticulum stress. J Gastroenterol 2017; 52:611-622. [PMID: 27599972 DOI: 10.1007/s00535-016-1256-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 08/26/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acetaminophen (APAP) overdose induces severe oxidative stress followed by hepatocyte apoptosis/necrosis. Previous studies have indicated that endoplasmic reticulum (ER) stress is involved in the cell death process. Therefore, we investigated the effect of the chemical chaperone 4-phenyl butyric acid (PBA) on APAP-induced liver injury in mice. METHODS Eight-week-old male C57Bl6/J mice were given a single intraperitoneal (i.p.) injection of APAP (450 mg/kg body weight), following which some were repeatedly injected with PBA (120 mg/kg body weight, i.p.) every 3 h starting at 0.5 h after the APAP challenge. All mice were then serially euthanized up to 12 h later. RESULTS PBA treatment dramatically ameliorated the massive hepatocyte apoptosis/necrosis that was observed 6 h after APAP administration. PBA also significantly prevented the APAP-induced increases in cleaved activating transcription factor 6 and phosphorylation of c-Jun N-terminal protein kinase and significantly blunted the increases in mRNA levels for binding immunoglobulin protein, spliced X-box binding protein-1, and C/EBP homologous protein. Moreover, PBA significantly prevented APAP-induced Bax translocation to the mitochondria, and the expression of heme oxygenase-1 mRNA and 4-hydroxynonenal. By contrast, PBA did not affect hepatic glutathione depletion following APAP administration, reflecting APAP metabolism. CONCLUSIONS PBA prevents APAP-induced liver injury even when an APAP challenge precedes its administration. The underlying mechanism of action most likely involves the prevention of ER stress-induced apoptosis/necrosis in the hepatocytes during APAP intoxication.
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29
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Endoplasmic reticulum stress inhibition reduces hypertension through the preservation of resistance blood vessel structure and function. J Hypertens 2016; 34:1556-69. [DOI: 10.1097/hjh.0000000000000943] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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30
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Ito S, Hayashi H, Sugiura T, Ito K, Ueda H, Togawa T, Endo T, Tanikawa K, Kage M, Kusuhara H, Saitoh S. Effects of 4-phenylbutyrate therapy in a preterm infant with cholestasis and liver fibrosis. Pediatr Int 2016; 58:506-509. [PMID: 26841694 DOI: 10.1111/ped.12839] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 08/19/2015] [Accepted: 10/09/2015] [Indexed: 01/05/2023]
Abstract
The bile salt export pump is expressed at the canalicular membrane of hepatocytes and mediates biliary excretion of bile salts. 4-Phenylbutyrate (4 PB), a drug used to treat ornithine transcarbamylase deficiency, has been found to increase the hepatocanalicular expression of bile salt export pump. The beneficial effects of 4-phenylbutyrate therapy have been reported for patients with progressive familial intrahepatic cholestasis, an inherited autosomal recessive liver disease. This is the first study to show the therapeutic effect of 4 PB in a preterm infant with cholestasis and liver fibrosis. The preterm infant had severe cholestasis with jaundice and failure to thrive refractory to ursodeoxycholic acid. Histology indicated giant cell hepatitis, cholestasis, and severe fibrosis. Bile salt export pump immunostaining showed lower expression than in a control. Oral 4 PB was started at a daily dose of 200 mg/kg/day. After the start of 4 PB therapy, cholestasis improved.
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Affiliation(s)
- Shogo Ito
- Department of Pediatrics and Neonatology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Hisamitsu Hayashi
- Laboratory of Molecular Pharmacokinetics, Graduate School of Pharmaceutical Sciences, University of Tokyo, Tokyo, Japan
| | - Tokio Sugiura
- Department of Pediatrics and Neonatology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Koichi Ito
- Department of Pediatrics and Neonatology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Hiroko Ueda
- Department of Pediatrics and Neonatology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Takao Togawa
- Department of Pediatrics and Neonatology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Takeshi Endo
- Department of Pediatrics and Neonatology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Ken Tanikawa
- Department of Diagnostic Pathology, Kurume University Hospital, Fukuoka, Japan
| | - Masayoshi Kage
- Department of Diagnostic Pathology, Kurume University Hospital, Fukuoka, Japan
| | - Hiroyuki Kusuhara
- Laboratory of Molecular Pharmacokinetics, Graduate School of Pharmaceutical Sciences, University of Tokyo, Tokyo, Japan
| | - Shinji Saitoh
- Department of Pediatrics and Neonatology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
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31
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Switch from Sodium Phenylbutyrate to Glycerol Phenylbutyrate Improved Metabolic Stability in an Adolescent with Ornithine Transcarbamylase Deficiency. JIMD Rep 2016; 31:11-14. [PMID: 27000017 DOI: 10.1007/8904_2016_551] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 02/25/2016] [Accepted: 02/29/2016] [Indexed: 12/30/2022] Open
Abstract
A male patient, born in 1999, was diagnosed with ornithine transcarbamylase deficiency as neonate and was managed with a strict low-protein diet supplemented with essential amino acids, L-citrulline, and L-arginine as well as sodium benzoate. He had an extensive history of hospitalizations for hyperammonemic crises throughout childhood and early adolescence, which continued after the addition of sodium phenylbutyrate in 2009. In December 2013 he was switched to glycerol phenylbutyrate, and his metabolic stability was greatly improved over the following 7 months prior to liver transplant.
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32
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Hook D, Diaz GA, Lee B, Bartley J, Longo N, Berquist W, Le Mons C, Rudolph-Angelich I, Porter M, Scharschmidt BF, Mokhtarani M. Protein and calorie intakes in adult and pediatric subjects with urea cycle disorders participating in clinical trials of glycerol phenylbutyrate. Mol Genet Metab Rep 2016; 6:34-40. [PMID: 27014577 PMCID: PMC4789342 DOI: 10.1016/j.ymgmr.2015.11.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 11/04/2015] [Indexed: 12/30/2022] Open
Abstract
Background Little prospectively collected data are available comparing the dietary intake of urea cycle disorder (UCD) patients to UCD treatment guidelines or to healthy individuals. Objective To examine the protein and calorie intakes of UCD subjects who participated in clinical trials of glycerol phenylbutyrate (GPB) and compare these data to published UCD dietary guidelines and nutritional surveys. Design Dietary data were recorded for 45 adult and 49 pediatric UCD subjects in metabolic control during participation in clinical trials of GPB. Protein and calorie intakes were compared to UCD treatment guidelines, average nutrient intakes of a healthy US population based on the National Health and Nutrition Examination Survey (NHANES) and Recommended Daily Allowances (RDA). Results In adults, mean protein intake was higher than UCD recommendations but lower than RDA and NHANES values, while calorie intake was lower than UCD recommendations, RDA and NHANES. In pediatric subjects, prescribed protein intake was higher than UCD guidelines, similar to RDA, and lower than NHANES data for all age groups, while calorie intake was at the lower end of the recommended UCD range and close to RDA and NHANES data. In pediatric subjects height, weight, and body mass index (BMI) Z-scores were within normal range (− 2 to 2). Conclusions Pediatric patients treated with phenylbutyrate derivatives exhibited normal height and weight. Protein and calorie intakes in adult and pediatric UCD subjects differed from UCD dietary guidelines, suggesting that these guidelines may need to be reconsidered.
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Affiliation(s)
- Debra Hook
- Miller Children's Hospital/Long Beach Medical Center, United States
| | - George A Diaz
- Mount Sinai School of Medicine, Department of Genetics and Genomic Sciences, Department of Pediatrics, United States
| | | | - James Bartley
- Miller Children's Hospital/Long Beach Medical Center, United States
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33
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Hong YP, Guo WY, Wang WX, Zhao L, Xiang MW, Mei FC, Abliz A, Hu P, Deng WH, Yu J. 4-Phenylbutyric Acid Attenuates Pancreatic Beta-Cell Injury in Rats with Experimental Severe Acute Pancreatitis. Int J Endocrinol 2016; 2016:4592346. [PMID: 27656209 PMCID: PMC5021485 DOI: 10.1155/2016/4592346] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 08/10/2016] [Indexed: 02/06/2023] Open
Abstract
Endoplasmic reticulum (ER) stress is a particular process with an imbalance of homeostasis, which plays an important role in pancreatitis, but little is known about how ER stress is implicated in severe acute pancreatitis (SAP) induced pancreatic beta-cell injury. To investigate the effect of 4-phenylbutyric acid (4-PBA) on the beta-cell injury following SAP and the underlying mechanism, twenty-four Sprague-Dawley rats were randomly divided into sham-operation (SO) group, SAP model group, and 4-PBA treatment group. SAP model was induced by infusion of 5% sodium taurocholate into the biliopancreatic duct. 4-PBA or normal saline was injected intraperitoneally for 3 days in respective group before successful modeling. Results showed that 4-PBA attenuated the following: (1) pancreas and islet pathological injuries, (2) serum TNF-α and IL-1β, (3) serum insulin and glucose, (4) beta-cell ultrastructural changes, (5) ER stress markers (BiP, ORP150, and CHOP), Caspase-3, and insulin expression in islet. These results suggested that 4-PBA mitigates pancreatic beta-cell injury and endocrine disorder in SAP, presumably because of its role in inhibiting excessive endoplasmic reticulum stress. This may serve as a new therapeutic target for reducing pancreatic beta-cell injury and endocrine disorder in SAP upon 4-PBA treatment.
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Affiliation(s)
- Yu-pu Hong
- Department of General Surgery, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, Hubei Province 430060, China
- Key Laboratory of Hubei Province for Digestive System Disease, 9 Zhangzhidong Road, Wuhan, Hubei Province 430060, China
| | - Wen-yi Guo
- Department of General Surgery, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, Hubei Province 430060, China
| | - Wei-xing Wang
- Department of General Surgery, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, Hubei Province 430060, China
- *Wei-xing Wang:
| | - Liang Zhao
- Department of General Surgery, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, Hubei Province 430060, China
- Central Laboratory, Renmin Hospital of Wuhan University, 9 Zhangzhidong Road, Wuhan, Hubei Province 430060, China
| | - Ming-wei Xiang
- Department of General Surgery, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, Hubei Province 430060, China
- Central Laboratory, Renmin Hospital of Wuhan University, 9 Zhangzhidong Road, Wuhan, Hubei Province 430060, China
| | - Fang-chao Mei
- Department of General Surgery, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, Hubei Province 430060, China
- Key Laboratory of Hubei Province for Digestive System Disease, 9 Zhangzhidong Road, Wuhan, Hubei Province 430060, China
| | - Ablikim Abliz
- Department of General Surgery, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, Hubei Province 430060, China
| | - Peng Hu
- Department of General Surgery, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, Hubei Province 430060, China
| | - Wen-hong Deng
- Department of General Surgery, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, Hubei Province 430060, China
| | - Jia Yu
- Department of General Surgery, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, Hubei Province 430060, China
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Kim SR, Kim HJ, Kim DI, Lee KB, Park HJ, Jeong JS, Cho SH, Lee YC. Blockade of Interplay between IL-17A and Endoplasmic Reticulum Stress Attenuates LPS-Induced Lung Injury. Am J Cancer Res 2015; 5:1343-62. [PMID: 26516372 PMCID: PMC4615737 DOI: 10.7150/thno.11685] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 08/30/2015] [Indexed: 12/22/2022] Open
Abstract
IL-17 is a cytokine mainly from IL-17-producing T cells, which are one of subsets of CD4+ T cells and play a role in adaptive immune system. Recent studies have demonstrated that IL-17A can act rapidly as an innate immune responder during infection before the onset of its classic adaptive immune response. This role of IL-17A in innate immune response is implicated in lipopolysaccharide (LPS)-induced lung inflammation. Very recently, we have reported that endoplasmic reticulum (ER) stress is involved in LPS-induced lung inflammation in vivo and in vitro. This study aimed to elucidate the role of IL-17A in LPS-induced lung injury, focusing on the link with ER stress. We treated a murine model of LPS-induced lung injury with IL-17A neutralizing antibody and 4-phenylbutyrate (4-PBA), a representative ER stress inhibitor. In addition, we evaluated the effects of IL-17A on ER stress in LPS-stimulated bronchial epithelial cells. Our results showed that inhibition of IL-17A decreased LPS-induced pulmonary neutrophilia, vascular leakage, nuclear translocation of nuclear factor-κB (NF-κB), infiltration of dendritic cells, increased expression of Toll-like receptor 4 (TLR4), activation of NLRP3 inflammasome, and increased ER stress in the lung. 4-PBA or TAK-242, a TLR4 inhibitor attenuated expression of IL-17A thereby improving LPS-induced lung inflammation. Intriguingly, we observed that stimulation with LPS increased expression of IL-17A in airway epithelial cells and co-stimulation with IL-17A further increased ER stress and NF-κB activation. This study indicates that the interrelationship between IL-17A and ER stress plays an important role in LPS-induced injury showing a positive feedback in airway epithelial cells and suggests that targeting their interaction can be a potential therapeutic approach to overcome one of severe refractory pulmonary disorders.
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Nagamani SCS, Diaz GA, Rhead W, Berry SA, Le Mons C, Lichter-Konecki U, Bartley J, Feigenbaum A, Schulze A, Longo N, Berquist W, Gallagher R, Bartholomew D, Harding CO, Korson MS, McCandless SE, Smith W, Vockley J, Kronn D, Zori R, Cederbaum S, Merritt JL, Wong D, Coakley DF, Scharschmidt BF, Dickinson K, Marino M, Lee BH, Mokhtarani M. Self-reported treatment-associated symptoms among patients with urea cycle disorders participating in glycerol phenylbutyrate clinical trials. Mol Genet Metab 2015; 116:29-34. [PMID: 26296711 PMCID: PMC4804346 DOI: 10.1016/j.ymgme.2015.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Accepted: 08/03/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Health care outcomes have been increasingly assessed through health-related quality of life (HRQoL) measures. While the introduction of nitrogen-scavenging medications has improved survival in patients with urea cycle disorders (UCDs), they are often associated with side effects that may affect patient compliance and outcomes. METHODS Symptoms commonly associated with nitrogen-scavenging medications were evaluated in 100 adult and pediatric participants using a non-validated UCD-specific questionnaire. Patients or their caregivers responded to a pre-defined list of symptoms known to be associated with the use of these medications. Responses were collected at baseline (while patients were receiving sodium phenylbutyrate [NaPBA]) and during treatment with glycerol phenylbutyrate (GPB). RESULTS After 3 months of GPB dosing, there were significant reductions in the proportion of patients with treatment-associated symptoms (69% vs. 46%; p<0.0001), the number of symptoms per patient (2.5 vs. 1.1; p<0.0001), and frequency of the more commonly reported individual symptoms such as body odor, abdominal pain, nausea, burning sensation in mouth, vomiting, and heartburn (p<0.05). The reduction in symptoms was observed in both pediatric and adult patients. The presence or absence of symptoms or change in severity did not correlate with plasma ammonia levels or NaPBA dose. CONCLUSIONS The reduction in symptoms following 3 months of open-label GPB dosing was similar in pediatric and adult patients and may be related to chemical structure and intrinsic characteristics of the product rather than its effect on ammonia control.
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Affiliation(s)
- Sandesh C S Nagamani
- Baylor College of Medicine, One Baylor Plaza, Room R814, Houston, TX 77030, USA.
| | - George A Diaz
- Icahn School of Medicine at Mount Sinai, Department of Genetics and Genomic Sciences, Department of Pediatrics, 1428 Madison Avenue, New York, NY 10029, USA
| | - William Rhead
- The Medical College of Wisconsin, MS 716, 9000 W. Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Susan A Berry
- University of Minnesota, 420 Delaware St. SE, MMC 75, Minneapolis, MN 55455, USA
| | - Cynthia Le Mons
- National Urea Cycle Disorders Foundation, 75 S. Grand Ave, Pasadena, CA 91105, USA
| | | | - James Bartley
- Long Beach Memorial Hospital, 2801 Atlantic Avenue, Long Beach, CA 90806, USA
| | | | - Andreas Schulze
- The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G1X8, Canada
| | - Nicola Longo
- The University of Utah, Division of Medical Genetics, 2C412 SOM, 50 North Mario Capecchi Drive, Salt Lake City, UT 84132, USA
| | - William Berquist
- Stanford University, 750 Welch Road, #116, Palo Alto, CA 94305, USA
| | - Renata Gallagher
- UCSF School of Medicine, 550 16th Street, San Francisco, CA 94158, USA
| | - Dennis Bartholomew
- Nationwide Children's Hospital, 545 South 18th Street, TH485, Columbus, OH 43205, USA
| | - Cary O Harding
- Oregon Health & Science University, 3181 SW Sam Jackson Park Road, A036/B198, Mail code L103, Portland, OR 97239, USA
| | - Mark S Korson
- Tufts Medical Center, Floating Building, 3rd Floor, 800 Washington Street, Boston, MA 02111, USA
| | - Shawn E McCandless
- Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Wendy Smith
- Maine Medical Center, 1577 Congress Street, 2nd Floor, Portland, ME 04102, USA
| | - Jerry Vockley
- Children's Hospital of Pittsburgh, One Children's Hospital Drive, 4401 Penn Avenue, Rangos Floor 5, Pittsburgh, PA 15224, USA
| | - David Kronn
- Westchester Medical Center, 503 Grasslands Road, Valhalla, NY 10595, USA
| | - Robert Zori
- University of Florida, UFHSC Box 100296, Gainesville, FL 32610, USA
| | - Stephen Cederbaum
- University of California, Los Angeles, 10833 Le Conte Avenue CHS 32-225, Los Angeles, CA 90095, USA
| | - J Lawrence Merritt
- Seattle Children's Hospital, 4800 Sand Point Way NE M/S W-65945, Seattle, WA 98105, USA
| | - Derek Wong
- University of California, Los Angeles, 10833 Le Conte Avenue CHS 32-225, Los Angeles, CA 90095, USA
| | - Dion F Coakley
- Horizon Therapeutics Inc., 2000 Sierra Point Parkway Suite 400, Brisbane, CA 94005, USA
| | - Bruce F Scharschmidt
- Horizon Therapeutics Inc., 2000 Sierra Point Parkway Suite 400, Brisbane, CA 94005, USA
| | - Klara Dickinson
- Anthera Pharmaceuticals, 25801 Industrial Blvd. Suite B, Hayward, CA 94545, USA
| | - Miguel Marino
- Oregon Health & Science University, 3181 SW Sam Jackson Park Road, A036/B198, Mail code L103, Portland, OR 97239, USA
| | - Brendan H Lee
- Baylor College of Medicine, One Baylor Plaza, Room R814, Houston, TX 77030, USA
| | - Masoud Mokhtarani
- Horizon Therapeutics Inc., 2000 Sierra Point Parkway Suite 400, Brisbane, CA 94005, USA
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Abstract
Hepatic encephalopathy (HE) is a common complication of cirrhosis, leading to frequent hospitalizations. Because ammonia is thought to play an important role in the pathogenesis of HE, therapies specifically aimed at reducing ammonia levels have been developed for conditions causing hyperammonemia, including HE. Ammonia scavengers have been used in HE patients, leading to improvements in symptoms. Bowel cleansing with polyethylene glycol has also been studied recently, resulting in more rapid improvement in acute HE compared with lactulose. Extracorporeal devices have been used in cases of refractory HE but currently are used primarily in research settings and not approved for clinical management for HE.
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Affiliation(s)
- Robert S Rahimi
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, 3410 Worth Street, Suite 860, Dallas, TX 75246, USA.
| | - Don C Rockey
- Department of Internal Medicine, Medical University of South Carolina, 96 Jonathan Lucas Street, Room 803 CSB, Charleston, SC 29425, USA
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Lee B, Diaz GA, Rhead W, Lichter-Konecki U, Feigenbaum A, Berry SA, Le Mons C, Bartley JA, Longo N, Nagamani SC, Berquist W, Gallagher R, Bartholomew D, Harding CO, Korson MS, McCandless SE, Smith W, Cederbaum S, Wong D, Merritt JL, Schulze A, Vockley J, Vockley G, Kronn D, Zori R, Summar M, Milikien DA, Marino M, Coakley DF, Mokhtarani M, Scharschmidt BF. Blood ammonia and glutamine as predictors of hyperammonemic crises in patients with urea cycle disorder. Genet Med 2015; 17:561-8. [PMID: 25503497 PMCID: PMC4465427 DOI: 10.1038/gim.2014.148] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Accepted: 09/17/2014] [Indexed: 11/18/2022] Open
Abstract
PURPOSE The aim of this study was to examine predictors of ammonia exposure and hyperammonemic crises in patients with urea cycle disorders. METHODS The relationships between fasting ammonia, daily ammonia exposure, and hyperammonemic crises were analyzed in >100 patients with urea cycle disorders. RESULTS Fasting ammonia correlated strongly with daily ammonia exposure (r = 0.764; P < 0.001). For patients with fasting ammonia concentrations <0.5 upper limit of normal (ULN), 0.5 to <1.0 ULN, and ≥1.0 ULN, the probability of a normal average daily ammonia value was 87, 60, and 39%, respectively, and 10.3, 14.1, and 37.0% of these patients, respectively, experienced ≥1 hyperammonemic crisis over 12 months. Time to first hyperammonemic crisis was shorter (P = 0.008) and relative risk (4.5×; P = 0.011) and rate (~5×, P = 0.006) of hyperammonemic crises were higher in patients with fasting ammonia ≥1.0 ULN vs. <0.5ULN; relative risk was even greater (20×; P = 0.009) in patients ≥6 years old. A 10- or 25-µmol/l increase in ammonia exposure increased the relative risk of a hyperammonemic crisis by 50 and >200% (P < 0.0001), respectively. The relationship between ammonia and hyperammonemic crisis risk seemed to be independent of treatment, age, urea cycle disorder subtype, dietary protein intake, or blood urea nitrogen. Fasting glutamine correlated weakly with daily ammonia exposure assessed as 24-hour area under the curve and was not a significant predictor of hyperammonemic crisis. CONCLUSION Fasting ammonia correlates strongly and positively with daily ammonia exposure and with the risk and rate of hyperammonemic crises, suggesting that patients with urea cycle disorder may benefit from tight ammonia control.
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Affiliation(s)
- Brendan Lee
- 1] Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA [2] Howard Hughes Medical Institute, Chevy Chase, Maryland, USA
| | - George A Diaz
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - William Rhead
- The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Annette Feigenbaum
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Susan A Berry
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Cindy Le Mons
- National Urea Cycle Disorders Foundation, Pasadena, California, USA
| | | | | | - Sandesh C Nagamani
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA
| | | | | | | | - Cary O Harding
- Oregon Health & Science University, Portland, Oregon, USA
| | | | - Shawn E McCandless
- University Hospitals Case Medical Center and Case Western Reserve University, Cleveland, Ohio, USA
| | | | | | - Derek Wong
- University of California, Los Angeles, Los Angeles, California, USA
| | | | - Andreas Schulze
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | | | - David Kronn
- Westchester Medical Center, Westchester, New York, USA
| | - Roberto Zori
- University of Florida, Gainesville, Florida, USA
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The therapeutic effects of 4-phenylbutyric acid in maintaining proteostasis. Int J Biochem Cell Biol 2015; 61:45-52. [PMID: 25660369 DOI: 10.1016/j.biocel.2015.01.015] [Citation(s) in RCA: 184] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Revised: 01/27/2015] [Accepted: 01/28/2015] [Indexed: 12/11/2022]
Abstract
Recently, there has been an increasing amount of literature published on the effects of 4-phenylbutyric acid (4-PBA) in various biological systems. 4-PBA is currently used clinically to treat urea cycle disorders under the trade name Buphenyl. Recent studies however have explored 4-PBA in the context of a low weight molecular weight chemical chaperone. Its properties as a chemical chaperone prevent misfolded protein aggregation and alleviate endoplasmic reticulum (ER) stress. As the ER is responsible for folding proteins targeted for use in membranes or secreted out of the cell, failure of maintaining adequate ER homeostasis may lead to protein misfolding and subsequent cell and organ pathology. Accumulation of misfolded proteins within the ER activates the unfolded protein response (UPR), a molecular repair response. The activation of the UPR aims to restore ER and cellular proteostasis by regulating the rate of synthesis of newly formed proteins as well as initiating molecular programs aimed to help fold or degrade misfolded proteins. If proteostasis is not restored, the UPR may initiate pro-apoptotic pathways. It is suggested that 4-PBA may help fold proteins in the ER, attenuating the activation of the UPR, and thus potentially alleviating various pathologies. This review discusses the biomedical research exploring the potential therapeutic effects of 4-PBA in various in vitro and in vivo model systems and clinical trials, while also commenting on the possible mechanisms of action.
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Abstract
Glycerol phenylbutyrate (GPB) is a new generation ammonia scavenger drug that was recently approved by the US FDA for chronic management in patients with urea cycle defect disorders after multicenter clinical trials. GPB is composed of three molecules of phenylbutyrate (PB) that are esterified to a glycerol backbone. The active agent, phenylacetate, is generated through multiple metabolic steps including hydrolysis in the small intestine by pancreatic triglyceride lipases. Its pharmacokinetic pattern is characterized by a slower release of the active metabolite than unconjugated PB, which contributes to superior ammonia control and fewer episodes of hyperammonemia. GPB is well tolerated with fewer gastrointestinal complications compared with sodium benzoate or PB. These unique features suggest that it may enhance adherence and, potentially, in improved outcomes in urea cycle disorder patients. GPB may have therapeutic potential in additional conditions such as chronic hepatic encephalopathy or other inherited metabolic disorders.
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Affiliation(s)
- Kimihiko Oishi
- a Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1497, New York, NY 10029, USA
- b Department of Pediatrics, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1497, New York, NY 10029, USA
| | - George A Diaz
- a Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1497, New York, NY 10029, USA
- b Department of Pediatrics, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1497, New York, NY 10029, USA
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40
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Berry SA, Lichter-Konecki U, Diaz GA, McCandless SE, Rhead W, Smith W, Lemons C, Nagamani SCS, Coakley DF, Mokhtarani M, Scharschmidt BF, Lee B. Glycerol phenylbutyrate treatment in children with urea cycle disorders: pooled analysis of short and long-term ammonia control and outcomes. Mol Genet Metab 2014; 112:17-24. [PMID: 24630270 PMCID: PMC4382922 DOI: 10.1016/j.ymgme.2014.02.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 02/06/2014] [Accepted: 02/09/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate glycerol phenylbutyrate (GPB) in the treatment of pediatric patients with urea cycle disorders (UCDs). STUDY DESIGN UCD patients (n=26) ages 2months through 17years were treated with GPB and sodium phenylbutyrate (NaPBA) in two short-term, open-label crossover studies, which compared 24-hour ammonia exposure (AUC0-24) and glutamine levels during equivalent steady-state dosing of GPB and sodium phenylbutyrate (NaPBA). These 26 patients plus an additional 23 patients also received GPB in one of three 12-month, open label extension studies, which assessed long-term ammonia control, hyperammonemic (HA) crises, amino acid levels, and patient growth. RESULTS Mean ammonia exposure on GPB was non-inferior to NaPBA in each of the individual crossover studies. In the pooled analyses, it was significantly lower on GPB vs. NaPBA (mean [SD] AUC0-24: 627 [302] vs. 872 [516] μmol/L; p=0.008) with significantly fewer abnormal values (15% on GPB vs. 35% on NaPBA; p=0.02). Mean ammonia levels remained within the normal range during 12months of GPB dosing and, when compared with the 12months preceding enrollment, a smaller percentage of patients (24.5% vs. 42.9%) experienced fewer (17 vs. 38) HA crises. Glutamine levels tended to be lower with GPB than with NaPBA during short-term dosing (mean [SD]: 660.8 [164.4] vs. 710.0 [158.7] μmol/L; p=0.114) and mean glutamine and branched chain amino acid levels, as well as other essential amino acids, remained within the normal range during 12months of GPB dosing. Mean height and weight Z-scores were within normal range at baseline and did not change significantly during 12months of GPB treatment. CONCLUSIONS Dosing with GPB was associated with 24-hour ammonia exposure that was non-inferior to that during dosing with NaPBA in individual studies and significantly lower in the pooled analysis. Long-term GPB dosing was associated with normal levels of glutamine and essential amino acids, including branched chain amino acids, age-appropriate growth and fewer HA crises as compared with the 12month period preceding enrollment.
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Affiliation(s)
| | | | - George A Diaz
- Icahn School of Medicine at Mount Sinai, Department of Genetics and Genomic Sciences, Department of Pediatrics, New York, NY, USA
| | | | - William Rhead
- The Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Cynthia Lemons
- National Urea Cycle Disorders Foundation, 75 S. Grand Ave., Pasadena, CA 91105, USA
| | | | | | | | | | - Brendan Lee
- Baylor College of Medicine, Houston, TX, USA
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Kwartler CS, Chen J, Thakur D, Li S, Baskin K, Wang S, Wang ZV, Walker L, Hill JA, Epstein HF, Taegtmeyer H, Milewicz DM. Overexpression of smooth muscle myosin heavy chain leads to activation of the unfolded protein response and autophagic turnover of thick filament-associated proteins in vascular smooth muscle cells. J Biol Chem 2014; 289:14075-88. [PMID: 24711452 DOI: 10.1074/jbc.m113.499277] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Duplications spanning nine genes at the genomic locus 16p13.1 predispose individuals to acute aortic dissections. The most likely candidate gene in this region leading to the predisposition for dissection is MYH11, which encodes smooth muscle myosin heavy chain (SM-MHC). The effects of increased expression of MYH11 on smooth muscle cell (SMC) phenotypes were explored using mouse aortic SMCs with transgenic overexpression of one isoform of SM-MHC. We found that these cells show increased expression of Myh11 and myosin filament-associated contractile genes at the message level when compared with control SMCs, but not at the protein level due to increased protein degradation. Increased expression of Myh11 resulted in endoplasmic reticulum (ER) stress in SMCs, which led to a paradoxical decrease of protein levels through increased autophagic degradation. An additional consequence of ER stress in SMCs was increased intracellular calcium ion concentration, resulting in increased contractile signaling and contraction. The increased signals for contraction further promote transcription of contractile genes, leading to a feedback loop of metabolic abnormalities in these SMCs. We suggest that overexpression of MYH11 can lead to increased ER stress and autophagy, findings that may be globally implicated in disease processes associated with genomic duplications.
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Affiliation(s)
| | - Jiyuan Chen
- From the Departments of Internal Medicine and
| | - Dhananjay Thakur
- Integrative Biology and Pharmacology, University of Texas Health Science Center, Houston, Texas 77030
| | - Shumin Li
- the Department of Biochemistry and Molecular Biology, University of Texas Medical Branch, Galveston, Texas 77555
| | | | | | - Zhao V Wang
- the Departments of Internal Medicine (Cardiology) and Molecular Biology, University of Texas Southwestern Medical Center, Dallas, Texas 75390, and
| | - Lori Walker
- the Department of Medicine, University of Colorado, Denver, Colorado 80217
| | - Joseph A Hill
- the Departments of Internal Medicine (Cardiology) and Molecular Biology, University of Texas Southwestern Medical Center, Dallas, Texas 75390, and
| | - Henry F Epstein
- the Department of Biochemistry and Molecular Biology, University of Texas Medical Branch, Galveston, Texas 77555
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Rockey DC, Vierling JM, Mantry P, Ghabril M, Brown RS, Alexeeva O, Zupanets IA, Grinevich V, Baranovsky A, Dudar L, Fadieienko G, Kharchenko N, Klaryts'ka I, Morozov V, Grewal P, McCashland T, Reddy KG, Reddy KR, Syplyviy V, Bass NM, Dickinson K, Norris C, Coakley D, Mokhtarani M, Scharschmidt BF. Randomized, double-blind, controlled study of glycerol phenylbutyrate in hepatic encephalopathy. Hepatology 2014; 59:1073-83. [PMID: 23847109 PMCID: PMC4237123 DOI: 10.1002/hep.26611] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 06/22/2013] [Indexed: 12/19/2022]
Abstract
UNLABELLED Glycerol phenylbutyrate (GPB) lowers ammonia by providing an alternate pathway to urea for waste nitrogen excretion in the form of phenylacetyl glutamine, which is excreted in urine. This randomized, double-blind, placebo-controlled phase II trial enrolled 178 patients with cirrhosis, including 59 already taking rifaximin, who had experienced two or more hepatic encephalopathy (HE) events in the previous 6 months. The primary endpoint was the proportion of patients with HE events. Other endpoints included the time to first event, total number of events, HE hospitalizations, symptomatic days, and safety. GPB, at 6 mL orally twice-daily, significantly reduced the proportion of patients who experienced an HE event (21% versus 36%; P=0.02), time to first event (hazard ratio [HR]=0.56; P<0.05), as well as total events (35 versus 57; P=0.04), and was associated with fewer HE hospitalizations (13 versus 25; P=0.06). Among patients not on rifaximin at enrollment, GPB reduced the proportion of patients with an HE event (10% versus 32%; P<0.01), time to first event (HR=0.29; P<0.01), and total events (7 versus 31; P<0.01). Plasma ammonia was significantly lower in patients on GPB and correlated with HE events when measured either at baseline or during the study. A similar proportion of patients in the GPB (79%) and placebo groups (76%) experienced adverse events. CONCLUSION GPB reduced HE events as well as ammonia in patients with cirrhosis and HE and its safety profile was similar to placebo. The findings implicate ammonia in the pathogenesis of HE and suggest that GPB has therapeutic potential in this population. (Clinicaltrials.gov, NCT00999167).
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Affiliation(s)
| | | | - Parvez Mantry
- Liver Institute at Methodist Dallas Medical CenterDallas, TX
| | | | | | - Olga Alexeeva
- Nizhny Novgorod Regional HospitalNizhny Novgorod, Russia
| | | | | | | | - Larysa Dudar
- O.O. Bogomolets, National Medical UniversityKiev, Ukraine
| | - Galyna Fadieienko
- State Institution “L.T. Malaya Institute of Therapy of NAMS of Ukraine,”Kharkiv, Ukraine
| | - Nataliya Kharchenko
- National Medical Academy of Postgraduate Education; Kiev City Clinical Hospital #8Kiev, Ukraine
| | - Iryna Klaryts'ka
- Crimean Republican Institution “M.O. Semashko Clinical Hospital,”Simferopol, Ukraine
| | | | - Priya Grewal
- Icahn School of Medicine at Mt. SinaiNew York, NY
| | | | | | | | | | - Nathan M Bass
- University of California San FranciscoSan Francisco, CA
| | | | | | - Dion Coakley
- Hyperion Therapeutics, Inc.South San Francisco, CA
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Carlisle RE, Brimble E, Werner KE, Cruz GL, Ask K, Ingram AJ, Dickhout JG. 4-Phenylbutyrate inhibits tunicamycin-induced acute kidney injury via CHOP/GADD153 repression. PLoS One 2014; 9:e84663. [PMID: 24416259 PMCID: PMC3885586 DOI: 10.1371/journal.pone.0084663] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 11/18/2013] [Indexed: 02/02/2023] Open
Abstract
Different forms of acute kidney injury (AKI) have been associated with endoplasmic reticulum (ER) stress; these include AKI caused by acetaminophen, antibiotics, cisplatin, and radiocontrast. Tunicamycin (TM) is a nucleoside antibiotic known to induce ER stress and is a commonly used inducer of AKI. 4-phenylbutyrate (4-PBA) is an FDA approved substance used in children who suffer from urea cycle disorders. 4-PBA acts as an ER stress inhibitor by aiding in protein folding at the molecular level and preventing misfolded protein aggregation. The main objective of this study was to determine if 4-PBA could protect from AKI induced by ER stress, as typified by the TM-model, and what mechanism(s) of 4-PBA's action were responsible for protection. C57BL/6 mice were treated with saline, TM or TM plus 4-PBA. 4-PBA partially protected the anatomic segment most susceptible to damage, the outer medullary stripe, from TM-induced AKI. In vitro work showed that 4-PBA protected human proximal tubular cells from apoptosis and TM-induced CHOP expression, an ER stress inducible proapoptotic gene. Further, immunofluorescent staining in the animal model found similar protection by 4-PBA from CHOP nuclear translocation in the tubular epithelium of the medulla. This was accompanied by a reduction in apoptosis and GRP78 expression. CHOP(-/-) mice were protected from TM-induced AKI. The protective effects of 4-PBA extended to the ultrastructural integrity of proximal tubule cells in the outer medulla. When taken together, these results indicate that 4-PBA acts as an ER stress inhibitor, to partially protect the kidney from TM-induced AKI through the repression of ER stress-induced CHOP expression.
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Affiliation(s)
- Rachel E. Carlisle
- Department of Medicine, Division of Nephrology, McMaster University and St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Elise Brimble
- Department of Medicine, Division of Nephrology, McMaster University and St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Kaitlyn E. Werner
- Department of Medicine, Division of Nephrology, McMaster University and St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Gaile L. Cruz
- Department of Medicine, Division of Nephrology, McMaster University and St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Kjetil Ask
- Department of Medicine, Division of Respirology, McMaster University and St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Alistair J. Ingram
- Department of Medicine, Division of Nephrology, McMaster University and St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Jeffrey G. Dickhout
- Department of Medicine, Division of Nephrology, McMaster University and St. Joseph's Healthcare Hamilton, Hamilton, Canada
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Mokhtarani M, Diaz GA, Rhead W, Berry SA, Lichter-Konecki U, Feigenbaum A, Schulze A, Longo N, Bartley J, Berquist W, Gallagher R, Smith W, McCandless SE, Harding C, Rockey DC, Vierling JM, Mantry P, Ghabril M, Brown RS, Dickinson K, Moors T, Norris C, Coakley D, Milikien DA, Nagamani SC, Lemons C, Lee B, Scharschmidt BF. Elevated phenylacetic acid levels do not correlate with adverse events in patients with urea cycle disorders or hepatic encephalopathy and can be predicted based on the plasma PAA to PAGN ratio. Mol Genet Metab 2013; 110:446-53. [PMID: 24144944 PMCID: PMC4108288 DOI: 10.1016/j.ymgme.2013.09.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 09/29/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Phenylacetic acid (PAA) is the active moiety in sodium phenylbutyrate (NaPBA) and glycerol phenylbutyrate (GPB, HPN-100). Both are approved for treatment of urea cycle disorders (UCDs) - rare genetic disorders characterized by hyperammonemia. PAA is conjugated with glutamine in the liver to form phenylacetyleglutamine (PAGN), which is excreted in urine. PAA plasma levels ≥ 500 μg/dL have been reported to be associated with reversible neurological adverse events (AEs) in cancer patients receiving PAA intravenously. Therefore, we have investigated the relationship between PAA levels and neurological AEs in patients treated with these PAA pro-drugs as well as approaches to identifying patients most likely to experience high PAA levels. METHODS The relationship between nervous system AEs, PAA levels and the ratio of plasma PAA to PAGN were examined in 4683 blood samples taken serially from: [1] healthy adults [2], UCD patients of ≥ 2 months of age, and [3] patients with cirrhosis and hepatic encephalopathy (HE). The plasma ratio of PAA to PAGN was analyzed with respect to its utility in identifying patients at risk of high PAA values. RESULTS Only 0.2% (11) of 4683 samples exceeded 500 μg/ml. There was no relationship between neurological AEs and PAA levels in UCD or HE patients, but transient AEs including headache and nausea that correlated with PAA levels were observed in healthy adults. Irrespective of population, a curvilinear relationship was observed between PAA levels and the plasma PAA:PAGN ratio, and a ratio>2.5 (both in μg/mL) in a random blood draw identified patients at risk for PAA levels>500 μg/ml. CONCLUSIONS The presence of a relationship between PAA levels and reversible AEs in healthy adults but not in UCD or HE patients may reflect intrinsic differences among the populations and/or metabolic adaptation with continued dosing. The plasma PAA:PAGN ratio is a functional measure of the rate of PAA metabolism and represents a useful dosing biomarker.
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Affiliation(s)
- M Mokhtarani
- Hyperion Therapeutics, 601 Gateway Blvd., Suite 200, South San Francisco, CA 94080, USA.
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45
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Monteleone JPR, Mokhtarani M, Diaz GA, Rhead W, Lichter-Konecki U, Berry SA, Lemons C, Dickinson K, Coakley D, Lee B, Scharschmidt BF. Population pharmacokinetic modeling and dosing simulations of nitrogen-scavenging compounds: disposition of glycerol phenylbutyrate and sodium phenylbutyrate in adult and pediatric patients with urea cycle disorders. J Clin Pharmacol 2013; 53:699-710. [PMID: 23775211 DOI: 10.1002/jcph.92] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 03/12/2013] [Indexed: 11/08/2022]
Abstract
Sodium phenylbutyrate and glycerol phenylbutyrate mediate waste nitrogen excretion in the form of urinary phenylacetylglutamine (PAGN) in patients with urea cycle disorders (UCDs); rare genetic disorders characterized by impaired urea synthesis and hyperammonemia. Sodium phenylbutyrate is approved for UCD treatment; the development of glycerol phenylbutyrate afforded the opportunity to characterize the pharmacokinetics (PK) of both compounds. A population PK model was developed using data from four Phase II/III trials that collectively enrolled patients ages 2 months to 72 years. Dose simulations were performed with particular attention to phenylacetic acid (PAA), which has been associated with adverse events in non-UCD populations. The final model described metabolite levels in plasma and urine for both drugs and was characterized by (a) partial presystemic metabolism of phenylbutyric acid (PBA) to PAA and/or PAGN, (b) slower PBA absorption and greater presystemic conversion with glycerol phenylbutyrate, (c) similar systemic disposition with saturable conversion of PAA to PAGN for both drugs, and (d) body surface area (BSA) as a significant covariate accounting for age-related PK differences. Dose simulations demonstrated similar PAA exposure following mole-equivalent PBA dosing of both drugs and greater PAA exposure in younger patients based on BSA.
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46
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Smith W, Diaz GA, Lichter-Konecki U, Berry SA, Harding CO, McCandless SE, LeMons C, Mauney J, Dickinson K, Coakley DF, Moors TL, Mokhtarani M, Mokhtarani M, Scharschmidt BF, Lee B. Ammonia control in children ages 2 months through 5 years with urea cycle disorders: comparison of sodium phenylbutyrate and glycerol phenylbutyrate. J Pediatr 2013; 162:1228-34, 1234.e1. [PMID: 23324524 PMCID: PMC4017326 DOI: 10.1016/j.jpeds.2012.11.084] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 10/02/2012] [Accepted: 11/29/2012] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To examine ammonia levels, pharmacokinetics, and safety of glycerol phenylbutyrate (GPB; also referred to as HPN-100) and sodium phenylbutyrate (NaPBA) in young children with urea cycle disorders (UCDs). STUDY DESIGN This open label switch-over study enrolled patients ages 29 days to under 6 years taking NaPBA. Patients underwent 24-hour blood and urine sampling on NaPBA and again on a phenylbutyric acid-equimolar dose of GPB and completed questionnaires regarding signs and symptoms associated with NaPBA and/or their UCD. RESULTS Fifteen patients (8 argininosuccinate lyase deficiency, 3 argininosuccinic acid synthetase deficiency, 3 ornithine transcarbamylase deficiency, 1 arginase deficiency) ages 2 months through 5 years enrolled in and completed the study. Daily ammonia exposure (24-hour area under the curve) was lower on GPB and met predefined noninferiority criteria (ratio of means 0.79; 95% CI 0.593-1.055; P=.03 Wilcoxon; 0.07 t test). Six patients experienced mild adverse events on GPB; there were no serious adverse events or significant laboratory changes. Liver tests and argininosuccinic acid levels among patients with argininosuccinate lyase deficiency were unchanged or improved on GPB. Eleven of 15 patients reported 35 symptoms on day 1; 23 of these 35 symptoms improved or resolved on GPB. Mean systemic exposure to phenylbutyric acid, phenylacetic acid, and phenylacetylglutamine (PAGN) were similar and phenylacetic acid exposure tended to be higher in the youngest children on both drugs. Urinary PAGN concentration was greater on morning voids and varied less over 24 hours on GPB versus NaPBA. CONCLUSIONS GPB results in more evenly distributed urinary output of PAGN over 24 hours were associated with fewer symptoms and offers ammonia control comparable with that observed with NaPBA in young children with UCDs.
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Affiliation(s)
- W Smith
- Maine Medical Center, 1577 Congress Street, 2nd Floor, Portland, ME 04102
| | - GA Diaz
- Mount Sinai School of Medicine, Department of Genetics and Genomic Sciences, Department of Pediatrics, 1428 Madison Avenue, New York, NY 10029
| | - U Lichter-Konecki
- Children’s National Medical Center, Division of Genetics and Metabolism, 111 Michigan Avenue NW #1950, Washington, DC 20010
| | - SA Berry
- University of Minnesota, 420 Delaware St. SE, MMC 75, Minneapolis, MN 55455
| | - CO Harding
- Oregon Health Sciences University, 3181 SW Sam Jackson Park Road, A036/B198, Mailcode L103, Portland, OR 97239
| | - SE McCandless
- University Hospitals Case Medical Center and Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106
| | - C LeMons
- National Urea Cycle Disorders Foundation, 75 South Grand Avenue, Pasadena, CA 91105
| | - J Mauney
- Chiltern, 2520 Independence Blvd., Ste. 202, Wilmington NC
| | - K Dickinson
- Hyperion Therapeutics, 601 Gateway Blvd, Suite 200, South San Francisco, CA 94080
| | - DF Coakley
- Hyperion Therapeutics, 601 Gateway Blvd, Suite 200, South San Francisco, CA 94080
| | - TL Moors
- Hyperion Therapeutics, 601 Gateway Blvd, Suite 200, South San Francisco, CA 94080
| | - M Mokhtarani
- Hyperion Therapeutics, 601 Gateway Blvd, Suite 200, South San Francisco, CA 94080
| | - M Mokhtarani
- Hyperion Therapeutics, 601 Gateway Blvd, Suite 200, South San Francisco, CA 94080
| | - BF Scharschmidt
- Hyperion Therapeutics, 601 Gateway Blvd, Suite 200, South San Francisco, CA 94080
| | - B Lee
- Baylor College of Medicine, One Baylor Plaza, Room R814, Houston, TX 77030,Howard Hughes Medical Institute, One Baylor Plaza, Room R814, Houston, TX 77030
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Diaz GA, Krivitzky LS, Mokhtarani M, Rhead W, Bartley J, Feigenbaum A, Longo N, Berquist W, Berry SA, Gallagher R, Lichter-Konecki U, Bartholomew D, Harding CO, Cederbaum S, McCandless SE, Smith W, Vockley G, Bart SA, Korson MS, Kronn D, Zori R, Merritt JL, C S Nagamani S, Mauney J, Lemons C, Dickinson K, Moors TL, Coakley DF, Scharschmidt BF, Lee B. Ammonia control and neurocognitive outcome among urea cycle disorder patients treated with glycerol phenylbutyrate. Hepatology 2013; 57:2171-9. [PMID: 22961727 PMCID: PMC3557606 DOI: 10.1002/hep.26058] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Accepted: 08/15/2012] [Indexed: 02/02/2023]
Abstract
UNLABELLED Glycerol phenylbutyrate is under development for treatment of urea cycle disorders (UCDs), rare inherited metabolic disorders manifested by hyperammonemia and neurological impairment. We report the results of a pivotal Phase 3, randomized, double-blind, crossover trial comparing ammonia control, assessed as 24-hour area under the curve (NH3 -AUC0-24hr ), and pharmacokinetics during treatment with glycerol phenylbutyrate versus sodium phenylbutyrate (NaPBA) in adult UCD patients and the combined results of four studies involving short- and long-term glycerol phenylbutyrate treatment of UCD patients ages 6 and above. Glycerol phenylbutyrate was noninferior to NaPBA with respect to ammonia control in the pivotal study, with mean (standard deviation, SD) NH3 -AUC0-24hr of 866 (661) versus 977 (865) μmol·h/L for glycerol phenylbutyrate and NaPBA, respectively. Among 65 adult and pediatric patients completing three similarly designed short-term comparisons of glycerol phenylbutyrate versus NaPBA, NH3 -AUC0-24hr was directionally lower on glycerol phenylbutyrate in each study, similar among all subgroups, and significantly lower (P < 0.05) in the pooled analysis, as was plasma glutamine. The 24-hour ammonia profiles were consistent with the slow-release behavior of glycerol phenylbutyrate and better overnight ammonia control. During 12 months of open-label glycerol phenylbutyrate treatment, average ammonia was normal in adult and pediatric patients and executive function among pediatric patients, including behavioral regulation, goal setting, planning, and self-monitoring, was significantly improved. CONCLUSION Glycerol phenylbutyrate exhibits favorable pharmacokinetics and ammonia control relative to NaPBA in UCD patients, and long-term glycerol phenylbutyrate treatment in pediatric UCD patients was associated with improved executive function (ClinicalTrials.gov NCT00551200, NCT00947544, NCT00992459, NCT00947297). (HEPATOLOGY 2012).
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Affiliation(s)
- George A Diaz
- Mount Sinai School of Medicine, Department of Genetics and Genomic Sciences, Department of Pediatrics, New York, NY, USA
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Ghabril M, Zupanets IA, Vierling J, Mantry P, Rockey D, Wolf D, O'Shea R, Dickinson K, Gillaspy H, Norris C, Coakley DF, Mokhtarani M, Scharschmidt BF. Glycerol Phenylbutyrate in Patients With Cirrhosis and Episodic Hepatic Encephalopathy: A Pilot Study of Safety and Effect on Venous Ammonia Concentration. Clin Pharmacol Drug Dev 2013; 2:278-84. [DOI: 10.1002/cpdd.18] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 01/30/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Marwan Ghabril
- Indiana University School of Medicine; Indianapolis, IN; USA
| | | | | | - Parvez Mantry
- Liver Institute at Methodist Dallas Medical Center; Dallas, TX; USA
| | - Don Rockey
- University of Texas; Southwestern, Dallas, TX; USA
| | - David Wolf
- New York Medical College; Valhalla, NY; USA
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Mokhtarani M, Diaz GA, Rhead W, Lichter-Konecki U, Bartley J, Feigenbaum A, Longo N, Berquist W, Berry SA, Gallagher R, Bartholomew D, Harding CO, Korson MS, McCandless SE, Smith W, Vockley J, Bart S, Kronn D, Zori R, Cederbaum S, Dorrani N, Merritt JL, Sreenath-Nagamani S, Summar M, Lemons C, Dickinson K, Coakley DF, Moors TL, Lee B, Scharschmidt BF. Urinary phenylacetylglutamine as dosing biomarker for patients with urea cycle disorders. Mol Genet Metab 2012; 107:308-14. [PMID: 22958974 PMCID: PMC3608516 DOI: 10.1016/j.ymgme.2012.08.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Revised: 08/07/2012] [Accepted: 08/07/2012] [Indexed: 11/22/2022]
Abstract
UNLABELLED We have analyzed pharmacokinetic data for glycerol phenylbutyrate (also GT4P or HPN-100) and sodium phenylbutyrate with respect to possible dosing biomarkers in patients with urea cycle disorders (UCD). STUDY DESIGN These analyses are based on over 3000 urine and plasma data points from 54 adult and 11 pediatric UCD patients (ages 6-17) who participated in three clinical studies comparing ammonia control and pharmacokinetics during steady state treatment with glycerol phenylbutyrate or sodium phenylbutyrate. All patients received phenylbutyric acid equivalent doses of glycerol phenylbutyrate or sodium phenylbutyrate in a cross over fashion and underwent 24-hour blood samples and urine sampling for phenylbutyric acid, phenylacetic acid and phenylacetylglutamine. RESULTS Patients received phenylbutyric acid equivalent doses of glycerol phenylbutyrate ranging from 1.5 to 31.8 g/day and of sodium phenylbutyrate ranging from 1.3 to 31.7 g/day. Plasma metabolite levels varied widely, with average fluctuation indices ranging from 1979% to 5690% for phenylbutyric acid, 843% to 3931% for phenylacetic acid, and 881% to 1434% for phenylacetylglutamine. Mean percent recovery of phenylbutyric acid as urinary phenylacetylglutamine was 66.4 and 69.0 for pediatric patients and 68.7 and 71.4 for adult patients on glycerol phenylbutyrate and sodium phenylbutyrate, respectively. The correlation with dose was strongest for urinary phenylacetylglutamine excretion, either as morning spot urine (r = 0.730, p < 0.001) or as total 24-hour excretion (r = 0.791 p<0.001), followed by plasma phenylacetylglutamine AUC(24-hour), plasma phenylacetic acid AUC(24-hour) and phenylbutyric acid AUC(24-hour). Plasma phenylacetic acid levels in adult and pediatric patients did not show a consistent relationship with either urinary phenylacetylglutamine or ammonia control. CONCLUSION The findings are collectively consistent with substantial yet variable pre-systemic (1st pass) conversion of phenylbutyric acid to phenylacetic acid and/or phenylacetylglutamine. The variability of blood metabolite levels during the day, their weaker correlation with dose, the need for multiple blood samples to capture trough and peak, and the inconsistency between phenylacetic acid and urinary phenylacetylglutamine as a marker of waste nitrogen scavenging limit the utility of plasma levels for therapeutic monitoring. By contrast, 24-hour urinary phenylacetylglutamine and morning spot urine phenylacetylglutamine correlate strongly with dose and appear to be clinically useful non-invasive biomarkers for compliance and therapeutic monitoring.
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Affiliation(s)
- M Mokhtarani
- Hyperion Therapeutics, 601 Gateway Blvd, Suite 200, South San Francisco, CA 94080, USA.
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Ammonia-lowering strategies for the treatment of hepatic encephalopathy. Clin Pharmacol Ther 2012; 92:321-31. [PMID: 22871998 DOI: 10.1038/clpt.2012.112] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hyperammonemia leads to neurotoxic levels of brain ammonia and is a major factor involved in the pathogenesis of hepatic encephalopathy (HE). Ammonia-lowering treatments primarily involve two strategies: inhibiting ammonia production and/or increasing ammonia removal. Targeting the gut has been the primary focus for many years, with the goal of inhibiting the generation of ammonia. However, in the context of liver failure, extrahepatic organs containing ammonia metabolic pathways have become new potential ammonia-lowering targets. Skeletal muscle has the capacity to remove ammonia by producing glutamine through the enzyme glutamine synthetase (amidation of glutamate) and, given its large mass, has the potential to be an important ammonia-removing organ. On the other hand, glutamine can be deaminated to glutamate by phosphate-activated glutaminase, thus releasing ammonia (ammonia rebound). Therefore, new treatment strategies are being focused on stimulating the removal of both ammonia and glutamine.
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