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Forny P, Hörster F, Baumgartner MR, Kölker S, Boy N. How guideline development has informed clinical research for organic acidurias (et vice versa). J Inherit Metab Dis 2023; 46:520-535. [PMID: 36591944 DOI: 10.1002/jimd.12586] [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: 10/10/2022] [Revised: 11/22/2022] [Accepted: 12/30/2022] [Indexed: 01/03/2023]
Abstract
Organic acidurias, such as glutaric aciduria type 1 (GA1), methylmalonic (MMA), and propionic aciduria (PA) are a prominent group of inherited metabolic diseases involving accumulation of eponymous metabolites causing endogenous intoxication. For all three conditions, guidelines for diagnosis and management have been developed and revised over the last years, resulting in three revisions for GA1 and one revision for MMA/PA. The process of clinical guideline development in rare metabolic disorders is challenged by the scarcity and limited quality of evidence available. The body of literature is often fragmentary and where information is present, it is usually derived from small sample sizes. Therefore, the development of guidelines for GA1 and MMA/PA was initially confronted with a poor evidence foundation that hindered formulation of concrete recommendations in certain contexts, triggering specific research projects and initiation of longitudinal, prospective observational studies using patient registries. Reversely, these observational studies contributed to evaluate the value of newborn screening, phenotypic diversities, and treatment effects, thus significantly improving the quality of evidence and directly influencing formulation and evidence levels of guideline recommendations. Here, we present insights into interactions between guideline development and (pre)clinical research for GA1 and MMA/PA, and demonstrate how guidelines gradually improved from revision to revision. We describe how clinical studies help to unravel the relative impact of therapeutic interventions on outcome and conclude that despite new and better quality of research data over the last decades, significant shortcomings of evidence regarding prognosis and treatment remain. It appears that development of clinical guidelines can directly help to guide research, and vice versa.
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Affiliation(s)
- Patrick Forny
- Division of Metabolism and Children's Research Center, University Children's Hospital, University of Zurich, Zurich, Switzerland
- Department of Cell Biology and Physiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Friederike Hörster
- Division of Neuropaediatrics and Metabolic Medicine, Department of General Paediatrics, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias R Baumgartner
- Division of Metabolism and Children's Research Center, University Children's Hospital, University of Zurich, Zurich, Switzerland
| | - Stefan Kölker
- Division of Neuropaediatrics and Metabolic Medicine, Department of General Paediatrics, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Nikolas Boy
- Division of Neuropaediatrics and Metabolic Medicine, Department of General Paediatrics, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
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2
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Scott EM, Wenger OK, Robinson E, Colling K, Brown MF, Hershberger J, Radhakrishnan K. Glycogen storage disease type 1a in the Ohio Amish. JIMD Rep 2022; 63:453-461. [PMID: 36101819 PMCID: PMC9458600 DOI: 10.1002/jmd2.12310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/03/2022] [Accepted: 06/08/2022] [Indexed: 11/11/2022] Open
Abstract
Glycogen storage disease type 1a (GSD1a) is an inborn error of glucose metabolism characterized by fasting hypoglycemia, hepatomegaly, and growth failure. Late complications include nephropathy and hepatic adenomas. We conducted a retrospective observational study on a cohort of Amish patients with GSD1a. A total of 15 patients cared for at a single center, with a median age of 9.9 years (range 0.25–24 years) were included. All patients shared the same founder variant in GCPC c.1039 C > T. The phenotype of this cohort demonstrated good metabolic control with median cohort triglyceride level slightly above normal, no need for continuous overnight feeds, and a higher quality of life compared to a previous GSD cohort. The most frequent complications were oral aversion, gross motor delay, and renal hyperfiltration. We discuss our unique care delivery at a single center that cares for Amish patients with inherited disorders.
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Affiliation(s)
- Ethan M. Scott
- New Leaf Center Clinic for Special Children Ohio USA
- Department of Pediatrics Akron Children's Hospital Akron Ohio USA
| | - Olivia K. Wenger
- New Leaf Center Clinic for Special Children Ohio USA
- Department of Pediatrics Akron Children's Hospital Akron Ohio USA
| | - Elizabeth Robinson
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition Cleveland Clinic Foundation Cleveland Ohio USA
| | - Kristina Colling
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition Cleveland Clinic Foundation Cleveland Ohio USA
| | - Miraides F. Brown
- Akron Children's Hospital Rebecca D Considine Research Institute Akron Ohio USA
| | | | - Kadakkal Radhakrishnan
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition Cleveland Clinic Foundation Cleveland Ohio USA
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3
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Alili JM, Berleur MP, Husson MC, Mention K, Schiff M, Arnoux JB, Brassier A, Guemman AS, Grisel C, Dubois S, Abi-Wardé MT, Broissand C, Servais A, Dao M, de Lonlay P. Intravenous administration of a branched-chain amino-acid-free solution in children and adults with acute decompensation of maple syrup urine disease: a prospective multicentre observational study. Orphanet J Rare Dis 2022; 17:202. [PMID: 35578286 PMCID: PMC9112564 DOI: 10.1186/s13023-022-02353-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 05/03/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Patients with maple syrup urine disease (MSUD) experiencing metabolic decompensations have traditionally been treated with branched-chain amino acid (BCAA)-free mixture via oral or nasogastric administration routes. In some patients, enteral administration is not possible, either because the patient presents with vomiting, coma, or refuses nasogastric administration, thus intravenous (IV) BCAA-free solution is an appropriate intervention for these challenging cases.
Aims
This study aimed to evaluate the effectiveness and safety of managing metabolic decompensations by administering an IV BCAA-free solution.
Methods
This is an observational prospective study of data from MSUD patients hospitalised for decompensation episodes between 2010 and 2016 at 6 centres for rare metabolic diseases in France.
Results
A total of 24 patients (16 males; 8 females) experiencing 126 MSUD metabolic decompensation episodes (39 in children; 87 in adults) were admitted to hospital. At presentation, mean leucine plasma concentration was ≥ 381 µmol/L in 113/126 (89.7%) episodes. Children were treated with continuous IV BCAA-free solution at doses of 0.8 to 2.0 g/kg/day, for 4.8 days and adults for 3.8 days at doses of 0.5 to 2.6 g/kg/day. In the efficacy set of 102 analysable episodes leucine concentrations were normalised (to below 381 µmol/L) in 82% (n = 18/22) of episodes in children and in 84% (n = 67/80) of episodes in adults. Mean time to leucine normalisation was 3.0 days. This was significantly (p < 0.001) shorter than the algorithmically predicted time to leucine normalisation with traditional BCAA-free mixture. Duration of hospitalisation was significantly longer for children than for adults (7.1 days in children vs 5.2 days in adults, p = 0.012). No treatment-related adverse events were reported in any patients on IV BCAA-free solution.
Conclusion
The IV BCAA-free solution is safe and effective in normalising leucine concentrations during MSUD decompensation episodes in both children and adults, offering a practical treatment alternative for those patients who cannot receive BCAA-free mixture via oral or nasogastric routes.
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Sánchez-Pintos P, Meavilla S, López-Ramos MG, García-Cazorla Á, Couce ML. Intravenous branched-chain amino-acid-free solution for the treatment of metabolic decompensation episodes in Spanish pediatric patients with maple syrup urine disease. Front Pediatr 2022; 10:969741. [PMID: 36046474 PMCID: PMC9420908 DOI: 10.3389/fped.2022.969741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 07/27/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Metabolic decompensation episodes (DEs) in Maple Syrup urine disease (MSUD) result in brain accumulation of toxic branched-chain amino acids (BCAAs) and their respective branched-chain α-keto acids that could induce neuroinflammation, disturb brain bioenergetics, and alter glutamate and glutamine synthesis. These episodes require immediate intervention to prevent irreversible neurological damage. Intravenous (IV) administration of BCAA-free solution could represent a powerful alternative for emergency treatment of decompensations. METHODS This pediatric series discusses the management of DEs in MSUD patients with IV BCAA-free solution, as an emergency treatment for DEs or as a prophylactic in cases requiring surgery. Clinical evolution, amino acid profile and adverse effects were evaluated. RESULTS We evaluated the use of BCAA-free solution in 5 DEs in 5 MSUD pediatric patients, all with significantly elevated plasma leucine levels at admission (699-3296 μmol/L) and in 1 episode of risk of DE due to surgery. Leucine normalization was achieved in all cases with resolution or improvement of clinical symptoms following IV BCAA-free solution. The duration of administration ranged from 3-20 days. Administration of IV BCAA-free solution at the beginning of a DE could reverse depletion of the amino acids that compete with BCAAs for the LAT1 transporter, and the observed depletion of alanine, despite IV alanine supplementation. No related adverse events were observed. CONCLUSIONS Administration of standardized IV BCAA-free solution in emergency settings constitutes an important and safe alternative for the treatment of DEs in MSUD, especially in pediatric patients for whom oral or enteral treatment is not viable.
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Affiliation(s)
- Paula Sánchez-Pintos
- Diagnosis and Treatment Unit of Congenital Metabolic Diseases, Department of Paediatrics, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain.,IDIS-Health Research Institute of Santiago de Compostela, Santiago de Compostela, Spain.,CIBERER, Instituto Salud Carlos III, Madrid, Spain.,MetabERN, European Reference Network for Rare Hereditary Metabolic Disorders, Udine, Italy
| | - Silvia Meavilla
- MetabERN, European Reference Network for Rare Hereditary Metabolic Disorders, Udine, Italy.,Metabolic Diseases Unit, Neurology Department, CIBERER and MetabERN, Sant Joan de Déu Hospital, Barcelona, Spain
| | - María Goretti López-Ramos
- MetabERN, European Reference Network for Rare Hereditary Metabolic Disorders, Udine, Italy.,Metabolic Diseases Unit, Neurology Department, CIBERER and MetabERN, Sant Joan de Déu Hospital, Barcelona, Spain
| | - Ángeles García-Cazorla
- MetabERN, European Reference Network for Rare Hereditary Metabolic Disorders, Udine, Italy.,Metabolic Diseases Unit, Neurology Department, CIBERER and MetabERN, Sant Joan de Déu Hospital, Barcelona, Spain
| | - Maria L Couce
- Diagnosis and Treatment Unit of Congenital Metabolic Diseases, Department of Paediatrics, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain.,IDIS-Health Research Institute of Santiago de Compostela, Santiago de Compostela, Spain.,CIBERER, Instituto Salud Carlos III, Madrid, Spain.,MetabERN, European Reference Network for Rare Hereditary Metabolic Disorders, Udine, Italy
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Venema A, Peeks F, de Bruijn‐van der Veen M, de Boer F, Fokkert‐Wilts MJ, Lubout CMA, Huskens B, Dumont E, Mulkens S, Derks TGJ. A retrospective study of eating and psychosocial problems in patients with hepatic glycogen storage diseases and idiopathic ketotic hypoglycemia: Towards a standard set of patient-reported outcome measures. JIMD Rep 2022; 63:29-40. [PMID: 35028269 PMCID: PMC8743343 DOI: 10.1002/jmd2.12253] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/06/2021] [Accepted: 09/29/2021] [Indexed: 02/05/2023] Open
Abstract
There is a paucity in literature on eating and psychosocial problems in patients with hepatic glycogen storage disease (GSD) and idiopathic ketotic hypoglycemia (IKH), problems that can greatly affect quality of life. This is a monocentre, retrospective, observational mixed method study of patients with hepatic GSD or IKH treated at the Beatrix Children's Hospital Groningen, who had been referred to SeysCentra, a specialist centre for the treatment of eating problems. Additionally, a systematic literature review has been performed to identify instruments to quantify patient-reported outcome measures of psychosocial problems in hepatic GSD patients. Sixteen patients from 12 families were included with ages ranging between 3 and 24 years. Five out of sixteen patients were diagnosed with Avoidant/Restrictive Food Intake Disorder and six patients showed characteristics of this disorder. Fourteen patients experienced sleeping problems, and 11 out of 12 parent couples experienced stress about the illness of their child. We subsequently identified 26 instruments to quantify patient-reported outcome measures for GSD patients. This study demonstrates that GSD patients can develop Avoidant/Restrictive Food Intake Disorder influencing quality of life at multiple domains. The identification of instruments to assess psychosocial wellbeing is an important step towards a standard set of patient-reported outcome measures.
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Affiliation(s)
- Annieke Venema
- Department of Metabolic Diseases, Beatrix Children's Hospital, University Medical Centre GroningenUniversity of GroningenGroningenThe Netherlands
| | - Fabian Peeks
- Department of Metabolic Diseases, Beatrix Children's Hospital, University Medical Centre GroningenUniversity of GroningenGroningenThe Netherlands
| | - Marlies de Bruijn‐van der Veen
- Department of Metabolic Diseases, Beatrix Children's Hospital, University Medical Centre GroningenUniversity of GroningenGroningenThe Netherlands
| | - Foekje de Boer
- Department of Metabolic Diseases, Beatrix Children's Hospital, University Medical Centre GroningenUniversity of GroningenGroningenThe Netherlands
| | - Marieke J. Fokkert‐Wilts
- Department of Metabolic Diseases, Beatrix Children's Hospital, University Medical Centre GroningenUniversity of GroningenGroningenThe Netherlands
| | - Charlotte M. A. Lubout
- Department of Metabolic Diseases, Beatrix Children's Hospital, University Medical Centre GroningenUniversity of GroningenGroningenThe Netherlands
| | - Bibi Huskens
- SeysCentra, Center for Paediatric Eating Problems and IncontinenceMaldenThe Netherlands
| | - Eric Dumont
- SeysCentra, Center for Paediatric Eating Problems and IncontinenceMaldenThe Netherlands
- Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine, and Life SciencesMaastricht UniversityMaastrichtThe Netherlands
- Department of Clinical Psychological Science, Faculty of Psychology and NeuroscienceMaastricht UniversityMaastrichtThe Netherlands
| | - Sandra Mulkens
- SeysCentra, Center for Paediatric Eating Problems and IncontinenceMaldenThe Netherlands
- Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine, and Life SciencesMaastricht UniversityMaastrichtThe Netherlands
- Department of Clinical Psychological Science, Faculty of Psychology and NeuroscienceMaastricht UniversityMaastrichtThe Netherlands
| | - Terry G. J. Derks
- Department of Metabolic Diseases, Beatrix Children's Hospital, University Medical Centre GroningenUniversity of GroningenGroningenThe Netherlands
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Derks TGJ, Rodriguez-Buritica DF, Ahmad A, de Boer F, Couce ML, Grünert SC, Labrune P, López Maldonado N, Fischinger Moura de Souza C, Riba-Wolman R, Rossi A, Saavedra H, Gupta RN, Valayannopoulos V, Mitchell J. Glycogen Storage Disease Type Ia: Current Management Options, Burden and Unmet Needs. Nutrients 2021; 13:3828. [PMID: 34836082 PMCID: PMC8621617 DOI: 10.3390/nu13113828] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/21/2021] [Accepted: 10/22/2021] [Indexed: 12/16/2022] Open
Abstract
Glycogen storage disease type Ia (GSDIa) is caused by defective glucose-6-phosphatase, a key enzyme in carbohydrate metabolism. Affected individuals cannot release glucose during fasting and accumulate excess glycogen and fat in the liver and kidney, putting them at risk of severe hypoglycaemia and secondary metabolic perturbations. Good glycaemic/metabolic control through strict dietary treatment and regular doses of uncooked cornstarch (UCCS) is essential for preventing hypoglycaemia and long-term complications. Dietary treatment has improved the prognosis for patients with GSDIa; however, the disease itself, its management and monitoring have significant physical, psychological and psychosocial burden on individuals and parents/caregivers. Hypoglycaemia risk persists if a single dose of UCCS is delayed/missed or in cases of gastrointestinal intolerance. UCCS therapy is imprecise, does not treat the cause of disease, may trigger secondary metabolic manifestations and may not prevent long-term complications. We review the importance of and challenges associated with achieving good glycaemic/metabolic control in individuals with GSDIa and how this should be balanced with age-specific psychosocial development towards independence, management of anxiety and preservation of quality of life (QoL). The unmet need for treatment strategies that address the cause of disease, restore glucose homeostasis, reduce the risk of hypoglycaemia/secondary metabolic perturbations and improve QoL is also discussed.
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Affiliation(s)
- Terry G. J. Derks
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University of Groningen, University Medical Center Groningen, 9700 RB Groningen, The Netherlands; (F.d.B.); (A.R.)
| | - David F. Rodriguez-Buritica
- Department of Pediatrics, Division of Medical Genetics, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston) and Children’s Memorial Hermann Hospital, Houston, TX 77030, USA; (D.F.R.-B.); (H.S.)
| | - Ayesha Ahmad
- Department of Pediatrics, Division of Pediatric Genetics, Metabolism and Genomic Medicine, University of Michigan, Ann Arbor, MI 48109, USA;
| | - Foekje de Boer
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University of Groningen, University Medical Center Groningen, 9700 RB Groningen, The Netherlands; (F.d.B.); (A.R.)
| | - María L. Couce
- IDIS, CIBERER, MetabERN, University Clinical Hospital of Santiago de Compostela, 15706 Santiago de Compostela, Spain;
| | - Sarah C. Grünert
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, Medical Center-University of Freiburg, 79106 Freiburg, Germany;
| | - Philippe Labrune
- APHP, Université Paris-Saclay, Hôpital Antoine-Béclère, 92140 Clamart, France;
- Inserm U 1195, Paris-Saclay University, 94276 Le Kremlin Bicêtre, France
| | - Nerea López Maldonado
- Piera Health Center, Catalan Institute of Health, 08007 Barcelona, Spain;
- Autonomous University of Barcelona, 08193 Barcelona, Spain
| | | | - Rebecca Riba-Wolman
- Connecticut Children’s Medical Center, Department of Pediatrics, Division of Endocrinology, University of Connecticut, Farmington, CT 06032, USA;
| | - Alessandro Rossi
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University of Groningen, University Medical Center Groningen, 9700 RB Groningen, The Netherlands; (F.d.B.); (A.R.)
- Department of Translational Medicine, Section of Paediatrics, University of Naples “Federico II”, 80131 Naples, Italy
| | - Heather Saavedra
- Department of Pediatrics, Division of Medical Genetics, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston) and Children’s Memorial Hermann Hospital, Houston, TX 77030, USA; (D.F.R.-B.); (H.S.)
| | - Rupal Naik Gupta
- Ultragenyx Pharmaceutical Inc., Novato, CA 94949, USA; (R.N.G.); (V.V.)
| | | | - John Mitchell
- Department of Pediatrics, Division of Pediatric Endocrinology, Montreal Children’s Hospital, McGill University Health Center, Montreal, QC H4A 3J1, Canada;
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