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Bernardini G, Braconi D, Zatkova A, Sireau N, Kujawa MJ, Introne WJ, Spiga O, Geminiani M, Gallagher JA, Ranganath LR, Santucci A. Alkaptonuria. Nat Rev Dis Primers 2024; 10:16. [PMID: 38453957 DOI: 10.1038/s41572-024-00498-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2024] [Indexed: 03/09/2024]
Abstract
Alkaptonuria is a rare inborn error of metabolism caused by the deficiency of homogentisate 1,2-dioxygenase activity. The consequent homogentisic acid (HGA) accumulation in body fluids and tissues leads to a multisystemic and highly debilitating disease whose main features are dark urine, ochronosis (HGA-derived pigment in collagen-rich connective tissues), and a painful and severe form of osteoarthropathy. Other clinical manifestations are extremely variable and include kidney and prostate stones, aortic stenosis, bone fractures, and tendon, ligament and/or muscle ruptures. As an autosomal recessive disorder, alkaptonuria affects men and women equally. Debilitating symptoms appear around the third decade of life, but a proper and timely diagnosis is often delayed due to their non-specific nature and a lack of knowledge among physicians. In later stages, patients' quality of life might be seriously compromised and further complicated by comorbidities. Thus, appropriate management of alkaptonuria requires a multidisciplinary approach, and periodic clinical evaluation is advised to monitor disease progression, complications and/or comorbidities, and to enable prompt intervention. Treatment options are patient-tailored and include a combination of medications, physical therapy and surgery. Current basic and clinical research focuses on improving patient management and developing innovative therapies and implementing precision medicine strategies.
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Affiliation(s)
- Giulia Bernardini
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Siena, Italy.
| | - Daniela Braconi
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Siena, Italy
| | - Andrea Zatkova
- Institute of Clinical and Translational Research, Biomedical Research Center of the Slovak Academy of Sciences, Bratislava, Slovakia
- Geneton Ltd, Bratislava, Slovakia
| | | | - Mariusz J Kujawa
- 2nd Department of Radiology, Medical University of Gdansk, Gdansk, Poland
| | - Wendy J Introne
- Human Biochemical Genetics Section, Medical Genetics Branch, Office of the Clinical Director, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Ottavia Spiga
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Siena, Italy
| | - Michela Geminiani
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Siena, Italy
| | - James A Gallagher
- Department of Musculoskeletal and Ageing Science, Institute of Life Course and Medical Sciences University of Liverpool, Liverpool, UK
| | - Lakshminarayan R Ranganath
- Department of Musculoskeletal and Ageing Science, Institute of Life Course and Medical Sciences University of Liverpool, Liverpool, UK
- Department of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool University Hospital, Liverpool, UK
| | - Annalisa Santucci
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Siena, Italy
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2
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Imrich R, Štofko J, Boča R, Rajnák C. Electronic structure and molecular properties of nitisinone and mesotrione in water. J Mol Model 2023; 29:370. [PMID: 37953387 PMCID: PMC10641058 DOI: 10.1007/s00894-023-05780-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/02/2023] [Indexed: 11/14/2023]
Abstract
CONTEXT Nitisinone is a medium-sized organic molecule that is used in treating hereditary tyrosinemia type 1 (HT-1). The structurally analogous mesotrione, however, is used as a pesticide/herbicide. What molecular properties are responsible for the similarity/dissimilarity of these molecules is investigated here. The solvent effect reduces the electron affinity to rather negative values and causes the negative electron affinity which manifests itself in a very high positive absolute reduction potential. METHODS B3LYP method was utilized for a geometry optimization of nitisinone and mesotrione in their neural and ionized (L0, L+, L-) forms of 6 structures. The calculations were conducted in water as a solvent using conductor-like polarizable continuum model (CPCM), nitisinone also in vacuo. The complete vibrational analysis at the true energy minimum allows evaluating the thermodynamic functions with focus to the zero-point energy and overall entropic term. The change of the Gibbs energy on reductions and/or oxidation facilitates evaluating the absolute reduction and absolute oxidation potentials. Also, DLPNO-CCSD(T) method that involves the major part of the correlation energy has been applied to nitisinone and mesotrione and their molecular ions.
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Affiliation(s)
- Richard Imrich
- Faculty of Health Sciences, University of Ss. Cyril and Methodius, 917 01, Trnava, Slovakia
| | - Juraj Štofko
- Faculty of Health Sciences, University of Ss. Cyril and Methodius, 917 01, Trnava, Slovakia
| | - Roman Boča
- Faculty of Health Sciences, University of Ss. Cyril and Methodius, 917 01, Trnava, Slovakia.
| | - Cyril Rajnák
- Faculty of Natural Sciences, University of Ss. Cyril and Methodius, 917 01, Trnava, Slovakia
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3
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Loret A, Jacob C, Mammou S, Bigot A, Blasco H, Audemard-Verger A, Schwartz IV, Mulleman D, Maillot F. Joint manifestations revealing inborn metabolic diseases in adults: a narrative review. Orphanet J Rare Dis 2023; 18:239. [PMID: 37563694 PMCID: PMC10416490 DOI: 10.1186/s13023-023-02810-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 07/06/2023] [Indexed: 08/12/2023] Open
Abstract
Inborn metabolic diseases (IMD) are rare conditions that can be diagnosed during adulthood. Patients with IMD may have joint symptoms and the challenge is to establish an early diagnosis in order to institute appropriate treatment and prevent irreversible damage. This review describes the joint manifestations of IMD that may be encountered in adults. The clinical settings considered were arthralgia and joint stiffness as well as arthritis. Unspecific arthralgias are often the first symptoms of hereditary hemochromatosis, chronic low back pain may reveal an intervertebral disc calcification in relation with alkaptonuria, and progressive joint stiffness may correspond to a mucopolysaccharidosis or mucolipidosis. Gaucher disease is initially revealed by painful acute attacks mimicking joint pain described as "bone crises". Some IMD may induce microcrystalline arthropathy. Beyond classical gout, there are also gouts in connection with purine metabolism disorders known as "enzymopathic gouts". Pyrophosphate arthropathy can also be part of the clinical spectrum of Gitelman syndrome or hypophosphatasia. Oxalate crystals arthritis can reveal a primary hyperoxaluria. Destructive arthritis may be indicative of Wilson's disease. Non-destructive arthritis may be seen in mevalonate kinase deficiency and familial hypercholesterolemia.
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Affiliation(s)
- Amaury Loret
- Department of Internal Medicine, University Hospital of Tours, Tours, France.
- Department of Rheumatology, University Hospital of Tours, Tours, France.
- Department of Internal Medicine, Hôpital Bretonneau, 2 Boulevard Tonnellé, CHRU de Tours, Tours cedex, 37044, France.
| | - Claire Jacob
- Department of Internal Medicine, University Hospital of Tours, Tours, France
| | - Saloua Mammou
- Department of Rheumatology, University Hospital of Tours, Tours, France
| | - Adrien Bigot
- Department of Internal Medicine, University Hospital of Tours, Tours, France
| | - Hélène Blasco
- Biochemistry laboratory, University Hospital of Tours, Tours, France
- UMR INSERM 1253, Tours, France
- Reference center for inherited metabolic diseases, Tours, France
| | | | - Ida Vd Schwartz
- Medical Genetics Service/Genetics Department, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre - RS, Brazil
| | - Denis Mulleman
- Department of Rheumatology, University Hospital of Tours, Tours, France
| | - François Maillot
- Department of Internal Medicine, University Hospital of Tours, Tours, France
- UMR INSERM 1253, Tours, France
- Reference center for inherited metabolic diseases, Tours, France
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4
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Boča R, Štofko J, Imrich R. Ab initio study of molecular properties of l-tyrosine. J Mol Model 2023; 29:245. [PMID: 37442864 PMCID: PMC10344843 DOI: 10.1007/s00894-023-05648-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 07/03/2023] [Indexed: 07/15/2023]
Abstract
CONTEXT l-Tyrosine is a naturally occurring agent that acts as a precursor in biosynthesis of monoaminergic neurotransmitters in brain such as dopamine, adrenaline, noradrenaline, and hormones like thyroxine and triiodothyronine. While l-tyrosine in vacuo adopts the canonical aminoacid form with -NH2 and -COOH functional groups, from neutral solutions, is crystallizes in the zwitterionic form possessing -NH3+ and -COO- groups. As l-tyrosine is non-innocent agent with respect to redox processes, redox ability in water expressed by the absolute oxidation and reduction potentials is investigated. The cluster analysis applied to a set of nine related neurotransmitters and trace amines confirms that l-tyrosine is mostly similar to aminoacid forms of phenylalanine, octopamine, and noradrenaline. METHODS The energetic data at the Hartree-Fock MO-LCAO-SCF method has been conducted using def2-TZVP basis set, and improved by the many-body perturbation theory using the MP2 correction to the correlation energy. For the aminoacid form and the zwitterionic form of l-tyrosine, a set of molecular descriptors has been evaluated (ionization energy, electron affinity, molecular electronegativity, chemical hardness, electrophilicity index, dipole moment, quadrupole moment, and dipole polarizability). The solvent effect (CPCM) is very expressive to the zwitterionic form and alters the sign of the electron affinity from positive to negative values. In parallel, density-functional theory with B3LYP variant in the same basis set has been employed for full geometry optimization of the neutral and ionized forms of l-tyrosine allowing assessing the adiabatic (a) ionization/affinity processes. The complete vibrational analysis enables evaluating thermodynamic functions such as the inner energy, enthalpy, entropy, Gibbs energy, and consequently the absolute oxidation and reduction potentials. Of applied methods, the most reliable are B3LYP(a) results that account to the correlation energy and the electron and nuclear relaxation during the ionization/affinity processes.
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Affiliation(s)
- Roman Boča
- Faculty of Health Sciences, University of SS Cyril and Methodius, 91701, Trnava, Slovakia.
| | - Juraj Štofko
- Faculty of Health Sciences, University of SS Cyril and Methodius, 91701, Trnava, Slovakia
| | - Richard Imrich
- Faculty of Health Sciences, University of SS Cyril and Methodius, 91701, Trnava, Slovakia
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Ranganath L, Khedr M, Milan AM, Davison AS, Norman BP, Janssen MCH, Lock E, Bou‐Gharios G, Gallagher JA. Increased prevalence of Parkinson's disease in alkaptonuria. JIMD Rep 2023; 64:282-292. [PMID: 37404676 PMCID: PMC10315388 DOI: 10.1002/jmd2.12367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 04/27/2023] [Indexed: 07/06/2023] Open
Abstract
Amongst a cohort of 88 alkaptonuria (AKU) patients attending the United Kingdom National Alkaptonuria Centre (NAC), four unrelated patients had co-existing Parkinson's disease (PD). Two of the NAC patients developed PD before receiving nitisinone (NIT) while the other two developed overt PD during NIT therapy. NIT lowers redox-active homogentisic acid (HGA) and profoundly increases tyrosine (TYR). A further unpublished case of a Dutch patient with AKU and PD on deep brain stimulation is included in this report. A Pubmed search revealed a further five AKU patients with PD, all without NIT usage. The prevalence of PD in AKU in the NAC appears to be nearly 20-times higher than in the non-AKU population (p < 0.001) even when adjusted for age. We propose that life-long exposure to redox-active HGA may account for the higher prevalence of PD in AKU. Furthermore, the appearance of PD in AKU patients during NIT therapy may be due to unmasking dopamine deficiency in susceptible individuals, as a result of the tyrosinaemia during NIT therapy inhibiting the rate-limiting brain tyrosine hydroxylase.
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Affiliation(s)
- Lakshminarayan Ranganath
- Department of Clinical Biochemistry and Metabolic MedicineRoyal Liverpool University HospitalLiverpoolUK
- Department of Musculoskeletal and Ageing Science, Institute of Life Course and Medical SciencesUniversity of LiverpoolLiverpoolUK
| | - Milad Khedr
- Department of Clinical Biochemistry and Metabolic MedicineRoyal Liverpool University HospitalLiverpoolUK
| | - Anna M. Milan
- Department of Clinical Biochemistry and Metabolic MedicineRoyal Liverpool University HospitalLiverpoolUK
| | - Andrew S. Davison
- Department of Clinical Biochemistry and Metabolic MedicineRoyal Liverpool University HospitalLiverpoolUK
| | - Brendan P. Norman
- Department of Musculoskeletal and Ageing Science, Institute of Life Course and Medical SciencesUniversity of LiverpoolLiverpoolUK
| | - Mirian C. H. Janssen
- Departments of Internal Medicine & PediatricsRadboud University Nijmegen Medical CentreNijmegenNetherlands
| | - Edward Lock
- School of Pharmacy and Biomolecular SciencesLiverpool John Moores UniversityLiverpoolUK
| | - George Bou‐Gharios
- Department of Musculoskeletal and Ageing Science, Institute of Life Course and Medical SciencesUniversity of LiverpoolLiverpoolUK
| | - James A. Gallagher
- Department of Musculoskeletal and Ageing Science, Institute of Life Course and Medical SciencesUniversity of LiverpoolLiverpoolUK
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Fayette MA, Booth KTA, Lynnes TC, Luna C, Minich DJ, Wilson TE, Miller MJ. Biochemical and molecular confirmation of alkaptonuria in a Sumatran orangutan (Pongo abelii). Mol Genet Metab 2023; 139:107628. [PMID: 37354891 DOI: 10.1016/j.ymgme.2023.107628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 06/26/2023]
Abstract
A 6-yr-old female orangutan presented with a history of dark urine that turned brown upon standing since birth. Repeated routine urinalysis and urine culture were unremarkable. Urine organic acid analysis showed elevation in homogentisic acid consistent with alkaptonuria. Sequence analysis identified a homozygous missense variant, c.1081G>A (p.Gly361Arg), of the homogentisate 1,2-dioxygenase (HGD) gene. Familial studies, molecular modeling, and comparison to human variant databases support this variant as the underlying cause of alkaptonuria in this orangutan. This is the first report of molecular confirmation of alkaptonuria in a nonhuman primate.
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Affiliation(s)
| | - Kevin T A Booth
- Indiana University School of Medicine, Department of Medical and Molecular Genetics, Indianapolis, IN 46202, USA
| | - Ty C Lynnes
- Indiana University School of Medicine, Department of Medical and Molecular Genetics, Indianapolis, IN 46202, USA
| | - Carolina Luna
- Indiana University School of Medicine, Department of Medical and Molecular Genetics, Indianapolis, IN 46202, USA
| | | | - Theodore E Wilson
- Indiana University School of Medicine, Department of Medical and Molecular Genetics, Indianapolis, IN 46202, USA
| | - Marcus J Miller
- Indiana University School of Medicine, Department of Medical and Molecular Genetics, Indianapolis, IN 46202, USA.
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7
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Genovese F, Frederiksen P, Bay-Jensen AC, Karsdal MA, Milan AM, Olsson B, Rudebeck M, Gallagher JA, Ranganath LR. Nitisinone Treatment Affects Biomarkers of Bone and Cartilage Remodelling in Alkaptonuria Patients. Int J Mol Sci 2023; 24:10996. [PMID: 37446173 DOI: 10.3390/ijms241310996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 07/15/2023] Open
Abstract
Nitisinone has been approved for treatment of alkaptonuria (AKU). Non-invasive biomarkers of joint tissue remodelling could aid in understanding the molecular changes in AKU pathogenesis and how these can be affected by treatment. Serological and urinary biomarkers of type I collagen and II collagen in AKU were investigated in patients enrolled in the randomized SONIA 2 (NCT01916382) clinical study at baseline and yearly until the end of the study (Year 4). The trajectories of the biomarkers over time were observed. After treatment with nitisinone, the biomarkers of type I collagen remodelling increased at Year 1 (19% and 40% increase in CTX-I and PRO-C1, respectively), which was potentially reflected in the higher degree of mobility seen following treatment. The biomarkers of type II collagen remodelling decreased over time in the nitisinone group: C2M showed a 9.7% decline at Year 1, and levels then remained stable over the following visits; CTX-II showed a 26% decline at Year 3 and 4 in the nitisinone-treated patients. Nitisinone treatment induced changes in biomarkers of bone and cartilage remodelling. These biomarkers can aid patient management and deepen our knowledge of the molecular mechanisms of this rare disease.
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Affiliation(s)
| | | | | | | | - Anna M Milan
- Department of Clinical Biochemistry and Metabolic Medicine, Liverpool Clinical Laboratories, Liverpool University Hospitals NHS Foundation Trust, Liverpool L69 3BX, UK
| | | | | | - James A Gallagher
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool L69 3BX, UK
| | - Lakshminarayan R Ranganath
- Department of Clinical Biochemistry and Metabolic Medicine, Liverpool Clinical Laboratories, Liverpool University Hospitals NHS Foundation Trust, Liverpool L69 3BX, UK
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8
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Ooi N, Cooper IR, Norman B, Gallagher JA, Sireau N, Bou-Gharios G, Ranganath LR, Savage VJ. Evaluation of Homogentisic Acid, a Prospective Antibacterial Agent Highlighted by the Suitability of Nitisinone in Alkaptonuria 2 (SONIA 2) Clinical Trial. Cells 2023; 12:1683. [PMID: 37443717 PMCID: PMC10341174 DOI: 10.3390/cells12131683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/07/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
Despite urgent warnings about the spread of multidrug-resistant bacteria, the antibiotic development pipeline has remained sparsely populated. Naturally occurring antibacterial compounds may provide novel chemical starting points for antibiotic development programs and should be actively sought out. Evaluation of homogentisic acid (HGA), an intermediate in the tyrosine degradation pathway, showed that the compound had innate activity against Gram-positive and Gram-negative bacteria, which was lost following conversion into the degradation product benzoquinone acetic acid (BQA). Anti-staphylococcal activity of HGA can be attributed to effects on bacterial membranes. Despite an absence of haemolytic activity, the compound was cytotoxic to human HepG2 cells. We conclude that the antibacterial activity and in vitro safety profile of HGA render it more suitable for use as a topical agent or for inclusion in a small-molecule medicinal chemistry program.
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Affiliation(s)
- Nicola Ooi
- Infex Therapeutics, Alderley Park, Macclesfield SK10 4TG, UK
| | - Ian R. Cooper
- Infex Therapeutics, Alderley Park, Macclesfield SK10 4TG, UK
| | - Brendan Norman
- Institute of Life Course and Medical Sciences, William Henry Duncan Building, University of Liverpool, Liverpool L7 8TX, UK
| | - James A. Gallagher
- Institute of Life Course and Medical Sciences, William Henry Duncan Building, University of Liverpool, Liverpool L7 8TX, UK
| | | | - George Bou-Gharios
- Institute of Life Course and Medical Sciences, William Henry Duncan Building, University of Liverpool, Liverpool L7 8TX, UK
| | - Lakshminarayan R. Ranganath
- Institute of Life Course and Medical Sciences, William Henry Duncan Building, University of Liverpool, Liverpool L7 8TX, UK
- Departments of Clinical Biochemistry and Metabolic Medicine, Liverpool University Hospitals NHS Foundation Trusts, Liverpool L7 8XP, UK
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Singh MK, Memon FA, Deokar SA, Achhapalia Y, Yeotiwad GR. A Previously Undiagnosed Case of Alkaptonuria in an 80-Year-Old Patient: A Case Report. Cureus 2023; 15:e35792. [PMID: 37025736 PMCID: PMC10072848 DOI: 10.7759/cureus.35792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2023] [Indexed: 03/07/2023] Open
Abstract
Alkaptonuria is a rare genetic metabolic disorder of autosomal recessive inheritance characterised by the accumulation of homogentisic acid in the body. It is diagnosed upon identification of characteristic symptoms, using various biochemical investigations, radiographic pictures, and a variety of specialised tests. Here we are discussing the case of an 80-year-old female patient with incidental findings of alkaptonuria. It is crucial to understand the fundamental diagnostic investigations that can be used in low-income nations or facilities where investigations like genetic testing, gas chromatography, and mass spectrometry are not readily available for the diagnosis of alkaptonuria.
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Khedr M, Sireau N, Bou‐Gharios G, Gallagher JA, Ranganath LR. First decade anniversary of the United Kingdom National Alkaptonuria Centre. JIMD Rep 2023; 64:212-213. [PMID: 36873083 PMCID: PMC9981412 DOI: 10.1002/jmd2.12340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 09/05/2022] [Accepted: 09/12/2022] [Indexed: 01/20/2023] Open
Affiliation(s)
- Milad Khedr
- Department of Clinical Biochemistry and Metabolic MedicineLiverpool University Hospitals NHS Foundation TrustsLiverpoolUK
| | | | | | | | - Lakshminarayan R. Ranganath
- Department of Clinical Biochemistry and Metabolic MedicineLiverpool University Hospitals NHS Foundation TrustsLiverpoolUK
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Ding H, Wang L, Feng GJ, Song YM, Liu LM. Case report: Thoracolumbar spinal stenosis associated with alkaptonuria. Front Surg 2023; 9:1040715. [PMID: 36684124 PMCID: PMC9852044 DOI: 10.3389/fsurg.2022.1040715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 11/08/2022] [Indexed: 01/07/2023] Open
Abstract
Background Alkaptonuria is a rare autosomal genetic disorder with an incidence of about 1 in 1 million per year. Spinal involvement often manifests in the later stages of the disease. However, this is the first report of the presentation of thoracolumbar spinal stenosis. Case presentation We report the case of a 61-year-old female patient with significant thoracolumbar stenosis symptoms. The patient had obvious kyphosis with preoperative lower extremity muscle strength grade 2/5. Symptoms and imaging signs initially suggested ankylosing spondylitis. This patient was classified into motor incomplete injury (ASIA C). However, the patient was found to have melanin deposits on the sclera and skin, and the urine was darkened at rest. CT and MRI both suggested no bone bridge connection between vertebrae, which was the key difference between ankylosing spondylitis and alkaptonuria in imaging. Most importantly, urine specimen testing and intraoperative pathology demonstrated alkaptonuria. The patient underwent spinal decompression and vertebral body fixation. Postoperative recovery was good: the patient had significantly relieved pain and could stand and walk. Conclusion This case is the first report of thoracolumbar spinal stenosis associated with alkaptonuria involving the spine.
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12
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Ranganath LR, Sireau N. Clinical development innovation in rare diseases: overcoming barriers to successful delivery of a randomised clinical trial in alkaptonuria-a mini-review. Orphanet J Rare Dis 2023; 18:1. [PMID: 36600285 PMCID: PMC9811731 DOI: 10.1186/s13023-022-02606-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/19/2022] [Indexed: 01/05/2023] Open
Abstract
Alkaptonuria is a rare inherited disorder for which there was no disease-modifying treatment. In order to develop a successful approved therapy of AKU multiple barriers had to be overcome. These included activities before the conduct of the study including deciding on the drug therapy, the dose of the drug to be used, clarify the nature of the disease, develop outcome measures likely to yield a positive outcome, have a strategy to ensure appropriate patient participation through identification, build a consortium of investigators, obtain regulatory approval for proposed investigation plan and secure funding. Significant barriers were overcome during the conduct of the multicentre study to ensure harmonisation. Mechanisms were put in place to recruit and retain patients in the study. Barriers to patient access following completion of the study and regulatory approval were resolved.
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Affiliation(s)
- L. R. Ranganath
- grid.415970.e0000 0004 0417 2395Department of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP UK ,grid.10025.360000 0004 1936 8470Department of Musculoskeletal Biology, University of Liverpool, Liverpool, L7 8TX UK
| | - Nick Sireau
- The Alkaptonuria Society, 66 Devonshire Road, Cambridge, CB1 2BL, UK.
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13
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Imrich R, Zatkova A, Lukacova O, Sedlakova J, Zanova E, Vlcek M, Penesova A, Radikova Z, Havranova A, Ranganath L. Nutritional interventions for patients with alkaptonuria: A minireview. Endocr Regul 2023; 57:61-67. [PMID: 36966367 DOI: 10.2478/enr-2023-0008] [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] [Indexed: 03/27/2023] Open
Abstract
Alkaptonuria (AKU, OMIM, No. 203500) is a rare, slow-progressing, irreversible, multisystemic disease resulting from a deficiency of the homogentisate 1,2-dioxygenase enzyme, which leads to the accumulation of homogentisic acid (HGA) and subsequent deposition as pigment in connective tissues called ochronosis. As a result, severe arthropathy of large joints and spondyloarthropathy with frequent fractures, ligament ruptures, and osteoporosis develops in AKU patients. Since 2020, the first-time treatment with nitisinone has become available in the European Union. Nitisinone significantly reduces HGA production and arrests ochronosis in AKU patients. However, blocking of the tyrosine metabolic pathway by the drug leads to tyrosine plasma and tissue concentrations increase. The nitisinone-induced hypertyrosinemia can lead to the development of corneal keratopathy, and once it develops, the treatment needs to be interrupted. A decrease in overall protein intake reduces the risk of the keratopathy during nitisinone-induced hypertyrosinemia in AKU patients. The low-protein diet is not only poorly tolerated by patients, but over longer periods, leads to a severe muscle loss and weight gain due to increased energy intake from carbohydrates and fats. Therefore, the development of novel nutritional approaches is required to prevent the adverse events due to nitisinone-induced hypertyrosinemia and the negative impact on skeletal muscle metabolism in AKU patients.
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Affiliation(s)
- Richard Imrich
- 1Biomedical Research Center, Slovak Academy of Sciences, Bratislava, Slovakia
- 2National Institute of Rheumatic Diseases, Piestany, Slovakia
| | - Andrea Zatkova
- 1Biomedical Research Center, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Olga Lukacova
- 2National Institute of Rheumatic Diseases, Piestany, Slovakia
| | - Jana Sedlakova
- 2National Institute of Rheumatic Diseases, Piestany, Slovakia
| | | | - Miroslav Vlcek
- 1Biomedical Research Center, Slovak Academy of Sciences, Bratislava, Slovakia
- 2National Institute of Rheumatic Diseases, Piestany, Slovakia
| | - Adela Penesova
- 1Biomedical Research Center, Slovak Academy of Sciences, Bratislava, Slovakia
- 2National Institute of Rheumatic Diseases, Piestany, Slovakia
| | - Zofia Radikova
- 1Biomedical Research Center, Slovak Academy of Sciences, Bratislava, Slovakia
- 2National Institute of Rheumatic Diseases, Piestany, Slovakia
| | - Andrea Havranova
- 1Biomedical Research Center, Slovak Academy of Sciences, Bratislava, Slovakia
- 2National Institute of Rheumatic Diseases, Piestany, Slovakia
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Bernini A, Spiga O, Santucci A. Structure-Function Relationship of Homogentisate 1,2-dioxygenase: Understanding the Genotype-Phenotype Correlations in the Rare Genetic Disease Alkaptonuria. Curr Protein Pept Sci 2023; 24:380-392. [PMID: 36880186 DOI: 10.2174/1389203724666230307104135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 01/16/2023] [Accepted: 01/26/2023] [Indexed: 03/08/2023]
Abstract
Alkaptonuria (AKU), a rare genetic disorder, is characterized by the accumulation of homogentisic acid (HGA) in organs, which occurs because the homogentisate 1,2-dioxygenase (HGD) enzyme is not functional due to gene variants. Over time, HGA oxidation and accumulation cause the formation of the ochronotic pigment, a deposit that provokes tissue degeneration and organ malfunction. Here, we report a comprehensive review of the variants so far reported, the structural studies on the molecular consequences of protein stability and interaction, and molecular simulations for pharmacological chaperones as protein rescuers. Moreover, evidence accumulated so far in alkaptonuria research will be re-proposed as the bases for a precision medicine approach in a rare disease.
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Affiliation(s)
- Andrea Bernini
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Italy
| | - Ottavia Spiga
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Italy
| | - Annalisa Santucci
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Italy
- Centro Regionale Medicina di Precisione, Siena, Italy
- ARTES 4.0, Pontedera, Italy
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15
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Davison AS, Norman BP. Alkaptonuria – Past, present and future. Adv Clin Chem 2023. [DOI: 10.1016/bs.acc.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
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16
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Ebrahim IC, Hoang TD, Vietor NO, Schacht JP, Shakir MKM. Dilemmas in the diagnosis and management of osteoporosis in a patient with alkaptonuria: Successful treatment with teriparatide. Clin Case Rep 2022; 10:e6729. [PMID: 36583204 PMCID: PMC9794677 DOI: 10.1002/ccr3.6729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/29/2022] Open
Abstract
Management of osteoporosis in patients with alkaptonuria can be challenging. This is the first case report confirming the effectiveness of teriparatide following zoledronic acid therapy in treating osteoporosis and preventing fragility fractures in a patient with alkaptonuria.
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Affiliation(s)
- Ismail C. Ebrahim
- Division of Endocrinology, Department of MedicineWalter Reed National Military Medical CenterBethesdaMarylandUSA
| | - Thanh D. Hoang
- Division of Endocrinology, Department of MedicineWalter Reed National Military Medical CenterBethesdaMarylandUSA,Division of Endocrinology, Department of MedicineUniformed Service University of the Health SciencesBethesdaMarylandUSA
| | - Nicole O. Vietor
- Division of Endocrinology, Department of MedicineWalter Reed National Military Medical CenterBethesdaMarylandUSA,Division of Endocrinology, Department of MedicineUniformed Service University of the Health SciencesBethesdaMarylandUSA
| | - John P. Schacht
- Department of GeneticsWalter Reed National Military Medical CenterBethesdaMarylandUSA
| | - Mohamed K. M. Shakir
- Division of Endocrinology, Department of MedicineWalter Reed National Military Medical CenterBethesdaMarylandUSA,Division of Endocrinology, Department of MedicineUniformed Service University of the Health SciencesBethesdaMarylandUSA
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17
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Alkaptonuria: Response to low-dose nitisinone in two patients with a new mutation. Med Clin (Barc) 2022; 159:604-605. [PMID: 36253209 DOI: 10.1016/j.medcli.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 08/30/2022] [Accepted: 08/30/2022] [Indexed: 11/07/2022]
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18
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Grasso D, Geminiani M, Galderisi S, Iacomelli G, Peruzzi L, Marzocchi B, Santucci A, Bernini A. Untargeted NMR Metabolomics Reveals Alternative Biomarkers and Pathways in Alkaptonuria. Int J Mol Sci 2022; 23:ijms232415805. [PMID: 36555443 PMCID: PMC9779518 DOI: 10.3390/ijms232415805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/04/2022] [Accepted: 12/10/2022] [Indexed: 12/15/2022] Open
Abstract
Alkaptonuria (AKU) is an ultra-rare metabolic disease caused by the accumulation of homogentisic acid (HGA), an intermediate product of phenylalanine and tyrosine degradation. AKU patients carry variants within the gene coding for homogentisate-1,2-dioxygenase (HGD), which are responsible for reducing the enzyme catalytic activity and the consequent accumulation of HGA and formation of a dark pigment called the ochronotic pigment. In individuals with alkaptonuria, ochronotic pigmentation of connective tissues occurs, leading to inflammation, degeneration, and eventually osteoarthritis. The molecular mechanisms underlying the multisystemic development of the disease severity are still not fully understood and are mostly limited to the metabolic pathway segment involving HGA. In this view, untargeted metabolomics of biofluids in metabolic diseases allows the direct investigation of molecular species involved in pathways alterations and their interplay. Here, we present the untargeted metabolomics study of AKU through the nuclear magnetic resonance of urine from a cohort of Italian patients; the study aims to unravel molecular species and mechanisms underlying the AKU metabolic disorder. Dysregulation of metabolic pathways other than the HGD route and new potential biomarkers beyond homogentisate are suggested, contributing to a more comprehensive molecular signature definition for AKU and the development of future adjuvant treatment.
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Affiliation(s)
- Daniela Grasso
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Via A, Moro 2, 53100 Siena, Italy
| | - Michela Geminiani
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Via A, Moro 2, 53100 Siena, Italy
| | - Silvia Galderisi
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Via A, Moro 2, 53100 Siena, Italy
| | - Gabriella Iacomelli
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Via A, Moro 2, 53100 Siena, Italy
| | - Luana Peruzzi
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Via A, Moro 2, 53100 Siena, Italy
| | - Barbara Marzocchi
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Via A, Moro 2, 53100 Siena, Italy
| | - Annalisa Santucci
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Via A, Moro 2, 53100 Siena, Italy
- Centro Regionale Medicina di Precisione, 53100 Siena, Italy
- ARTES 4.0, 56025 Pontedera, Italy
| | - Andrea Bernini
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Via A, Moro 2, 53100 Siena, Italy
- Correspondence:
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19
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Effects of Nitisinone on Oxidative and Inflammatory Markers in Alkaptonuria: Results from SONIA1 and SONIA2 Studies. Cells 2022; 11:cells11223668. [PMID: 36429096 PMCID: PMC9688277 DOI: 10.3390/cells11223668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/11/2022] [Accepted: 11/16/2022] [Indexed: 11/22/2022] Open
Abstract
Nitisinone (NTBC) was recently approved to treat alkaptonuria (AKU), but there is no information on its impact on oxidative stress and inflammation, which are observed in AKU. Therefore, serum samples collected during the clinical studies SONIA1 (40 AKU patients) and SONIA2 (138 AKU patients) were tested for Serum Amyloid A (SAA), CRP and IL-8 by ELISA; Advanced Oxidation Protein Products (AOPP) by spectrophotometry; and protein carbonyls by Western blot. Our results show that NTBC had no significant effects on the tested markers except for a slight but statistically significant effect for NTBC, but not for the combination of time and NTBC, on SAA levels in SONIA2 patients. Notably, the majority of SONIA2 patients presented with SAA > 10 mg/L, and 30 patients in the control group (43.5%) and 40 patients (58.0%) in the NTBC-treated group showed persistently elevated SAA > 10 mg/L at each visit during SONIA2. Higher serum SAA correlated with lower quality of life and higher morbidity. Despite no quantitative differences in AOPP, the preliminary analysis of protein carbonyls highlighted patterns that deserve further investigation. Overall, our results suggest that NTBC cannot control the sub-clinical inflammation due to increased SAA observed in AKU, which is also a risk factor for developing secondary amyloidosis.
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20
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A robust bacterial high-throughput screening system to evaluate single nucleotide polymorphisms of human homogentisate 1,2-dioxygenase in the context of alkaptonuria. Sci Rep 2022; 12:19452. [PMID: 36376482 PMCID: PMC9663557 DOI: 10.1038/s41598-022-23702-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 11/03/2022] [Indexed: 11/16/2022] Open
Abstract
Alkaptonuria (AKU) is a rare inborn error of metabolism caused by a defective homogentisate 1,2-dioxygenase (HGD), an enzyme involved in the tyrosine degradation pathway. Loss of HGD function leads to the accumulation of homogentisic acid (HGA) in connective body tissues in a process called ochronosis, which results on the long term in an early-onset and severe osteoarthropathy. HGD's quaternary structure is known to be easily disrupted by missense mutations, which makes them an interesting target for novel treatment strategies that aim to rescue enzyme activity. However, only prediction models are available providing information on a structural basis. Therefore, an E. coli based whole-cell screening was developed to evaluate HGD missense variants in 96-well microtiter plates. The screening principle is based on HGD's ability to convert the oxidation sensitive HGA into maleylacetoacetate. More precisely, catalytic activity could be deduced from pyomelanin absorbance measurements, derived from the auto-oxidation of remaining HGA. Optimized screening conditions comprised several E. coli expression strains, varied expression temperatures and varied substrate concentrations. In addition, plate uniformity, signal variability and spatial uniformity were investigated and optimized. Finally, eight HGD missense variants were generated via site-directed mutagenesis and evaluated with the developed high-throughput screening (HTS) assay. For the HTS assay, quality parameters passed the minimum acceptance criterion for Z' values > 0.4 and single window values > 2. We found that activity percentages versus wildtype HGD were 70.37 ± 3.08% (for M368V), 68.78 ± 6.40% (for E42A), 58.15 ± 1.16% (for A122V), 69.07 ± 2.26% (for Y62C), 35.26 ± 1.90% (for G161R), 35.86 ± 1.14% (for P230S), 23.43 ± 4.63% (for G115R) and 19.57 ± 11.00% (for G361R). To conclude, a robust, simple, and cost-effective HTS system was developed to reliably evaluate and distinguish human HGD missense variants by their HGA consumption ability. This HGA quantification assay may lay the foundation for the development of novel treatment strategies for missense variants in AKU.
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21
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Imrich R, Sedláková J, Úlehlová M, Gornall M, Jackson R, Olsson B, Rudebeck M, Gallagher J, Lukáčová O, Mlynáriková V, Stančík R, Vrtíková E, Záňová E, Zaťková A, Arnoux JB, Rovenský J, Luangrath E, Bygott H, Khedr M, Ranganath LR. Radiological evolution of spinal disease in alkaptonuria and the effect of nitisinone. RMD Open 2022; 8:rmdopen-2022-002422. [PMID: 36270742 PMCID: PMC9594597 DOI: 10.1136/rmdopen-2022-002422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 09/29/2022] [Indexed: 11/05/2022] Open
Abstract
Objectives Ochronotic spondyloarthropathy represents one of the main clinical manifestations of alkaptonuria (AKU); however, prospective data and description of the effect of nitisinone treatment are lacking. Methods Patients with AKU aged 25 years or older were randomly assigned to receive either oral nitisinone 10 mg/day (N=69) or no treatment (N=69). Spine radiographs were recorded yearly at baseline, 12, 24, 36 and 48 months, and the images were scored for the presence of intervertebral space narrowing, soft tissue calcifications, vacuum phenomena, osteophytes/hyperostosis and spinal fusion in the cervical, thoracic and lumbosacral segment at each of the time points. Results At baseline, narrowing of the intervertebral spaces, the presence of osteophytes/hyperostosis and calcifications were the three most frequent radiographic features in AKU. The rate of progression of the five main features during the 4 years, ranked from the highest to lowest was as follows: intervertebral spaces narrowing, calcifications, vacuum phenomena, osteophytes/hyperostosis and fusions. The rate of progression did not differ between the treated and untreated groups in any of the five radiographic parameters except for a slower rate of progression (sum of all five features) in the treatment group compared with the control group (0.45 (1.11) nitisinone vs 0.74 (1.11) controls, p=0.049) in the thoracic segment. Conclusion The present study shows a relatively slow but significant worsening of radiographic features in patients with AKU over 4 years. Our results demonstrate a modest beneficial effect of 10 mg/day of nitisinone on the slowly progressing spondylosis in AKU during the relatively limited follow-up time. Trial registration number NCT01916382.
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Affiliation(s)
- Richard Imrich
- Institute of Clinical and Translational Research, Biomedical Research Center Slovak Academy of Sciences, Bratislava, Slovakia,National Institute of Rheumatic Diseases, Piešťany, Slovakia
| | - Jana Sedláková
- National Institute of Rheumatic Diseases, Piešťany, Slovakia
| | - Mária Úlehlová
- National Institute of Rheumatic Diseases, Piešťany, Slovakia
| | | | | | | | | | - James Gallagher
- Musculoskeletal Biology, University of Liverpool, Liverpool, UK
| | - Oľga Lukáčová
- National Institute of Rheumatic Diseases, Piešťany, Slovakia
| | | | - Roman Stančík
- National Institute of Rheumatic Diseases, Piešťany, Slovakia
| | - Eva Vrtíková
- National Institute of Rheumatic Diseases, Piešťany, Slovakia
| | | | - Andrea Zaťková
- Institute of Clinical and Translational Research, Biomedical Research Center Slovak Academy of Sciences, Bratislava, Slovakia
| | | | - Jozef Rovenský
- National Institute of Rheumatic Diseases, Piešťany, Slovakia
| | - Emily Luangrath
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Helen Bygott
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Milad Khedr
- Clinical Biochemistry and Metabolic Medicine, Royal Liverpool University Hospital, Liverpool, UK
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22
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Zatkova A, Olsson B, Ranganath LR, Imrich R. Analysis of the Phenotype Differences in Siblings with Alkaptonuria. Metabolites 2022; 12:metabo12100990. [PMID: 36295892 PMCID: PMC9611385 DOI: 10.3390/metabo12100990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/14/2022] [Accepted: 10/15/2022] [Indexed: 11/16/2022] Open
Abstract
Alkaptonuria (AKU) is a rare autosomal recessive disorder caused by mutations within a gene coding for homogentisate 1,2-dioxygenase (HGD). To date, 251 different variants of this gene have been reported. The metabolic disorder in AKU leads to the accumulation of homogentisic acid (HGA), resulting in ochronosis (pigmentation of the connective tissues) and severe ochronotic spondylo-arthropathy, which usually manifests in the mid-thirties. An earlier genotype−phenotype correlation study showed no differences in serum HGA levels, absolute urinary excretion of HGA, or in the clinical symptoms between patients carrying HGD variants leading to 1% or >30% residual HGD activity. Still, as reported previously, the variance of the excretion of the HGA was smaller within affected siblings that share a common genotype. The present study is the first ever to systematically analyze the baseline clinical data of 24 AKU sibling pairs/groups collected in the SONIA 2 (Suitability Of Nitisinone In Alkaptonuria 2) study to evaluate phenotypical differences between patients carrying the same HGD genetic variants. We show that even between siblings there was considerable variability in the disease severity. This indicates that some other yet unidentified genetic, biomechanical, or environmental modifying factors may contribute to accelerated pigmentation and connective tissue damage observed in some patients.
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Affiliation(s)
- Andrea Zatkova
- Biomedical Research Center, Slovak Academy of Sciences, 845 05 Bratislava, Slovakia
- Correspondence: ; Tel.: +421-911-466599
| | | | - Lakshminarayan R. Ranganath
- Department of Clinical Biochemistry and Metabolism, Royal Liverpool University Hospital, Liverpool L7 8XP, UK
| | - Richard Imrich
- Biomedical Research Center, Slovak Academy of Sciences, 845 05 Bratislava, Slovakia
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23
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Revisiting Quantification of Phenylalanine/Tyrosine Flux in the Ochronotic Pathway during Long-Term Nitisinone Treatment of Alkaptonuria. Metabolites 2022; 12:metabo12100920. [PMID: 36295821 PMCID: PMC9610527 DOI: 10.3390/metabo12100920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/20/2022] [Accepted: 09/23/2022] [Indexed: 11/17/2022] Open
Abstract
Changes in the phenylalanine (PHE)/tyrosine (TYR) pathway metabolites before and during homogentisic acid (HGA)-lowering by nitisinone in the Suitability of Nitisinone in Alkaptonuria (AKU) 2 (SONIA 2) study enabled the magnitude of the flux in the pathway to be examined. SONIA 2 was a 48-month randomised, open-label, evaluator-blinded, parallel-group study performed in the UK, France and Slovakia recruiting patients with confirmed AKU to receive either 10 mg nitisinone or no treatment. Site visits were performed at 3 months and yearly thereafter. Results from history, photographs of eyes/ears, whole body scintigraphy, echocardiography and abdomen/pelvis ultrasonography were combined to produce the Alkaptonuria Severity Score Index (cAKUSSI). PHE, TYR, hydroxyphenylpyruvate (HPPA), hydroxyphenyllactate (HPLA) and HGA metabolites were analysed by liquid chromatography/tandem mass spectrometry in 24 h urine and serum samples collected before and during nitisinone. Serum metabolites were corrected for total body water (TBW), and the sum of 24 h urine plus total body water metabolites of PHE, TYR, HPPA, HPLA and HGA were determined. The sum of urine metabolites (PHE, TYR, HPPA, HPLA and HGA) were similar pre- and peri-nitisinone. The sum of TBW metabolites and sum TBW + URINE metabolites were significantly higher peri-nitisinone (p < 0.001 for both) compared with pre-nitisinone baseline. Significantly higher concentrations of metabolites from the tyrosine metabolic pathway were observed during treatment with nitisinone. Arguments for unmasking of the ochronotic pathway and biliary elimination of HGA are put forward.
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Determinants of tyrosinaemia during nitisinone therapy in alkaptonuria. Sci Rep 2022; 12:16083. [PMID: 36167967 PMCID: PMC9515198 DOI: 10.1038/s41598-022-20424-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 09/13/2022] [Indexed: 11/25/2022] Open
Abstract
Nitisinone (NIT) produces inevitable but varying degree of tyrosinaemia. However, the understanding of the dynamic adaptive relationships within the tyrosine catabolic pathway has not been investigated fully. The objective of the study was to assess the contribution of protein intake, serum NIT (sNIT) and tyrosine pathway metabolites to nitisinone-induced tyrosinaemia in alkaptonuria (AKU). Samples of serum and 24-h urine collected during SONIA 2 (Suitability Of Nitisinone In Alkaptonuria 2) at months 3 (V2), 12 (V3), 24 (V4), 36 (V5) and 48 (V6) were included in these analyses. Homogentisic acid (HGA), tyrosine (TYR), phenylalanine (PHE), hydroxyphenylpyruvate (HPPA), hydroxyphenyllactate (HPLA) and sNIT were analysed at all time-points in serum and urine. Total body water (TBW) metabolites were derived using 60% body weight. 24-h urine and TBW metabolites were summed to obtain combined values. All statistical analyses were post-hoc. 307 serum and 24-h urine sampling points were analysed. Serum TYR from V2 to V6, ranging from 478 to 1983 µmol/L were stratified (number of sampling points in brackets) into groups < 701 (47), 701–900 (105), 901–1100 (96) and > 1100 (59) µmol/L. The majority of sampling points had values greater than 900 µmol/L. sPHE increased with increasing sTYR (p < 0.001). Tyrosine, HPPA and HPLA in serum and TBW all increased with rising sTYR (p < 0.001), while HPLA/TYR ratio decreased (p < 0.0001). During NIT therapy, adaptive response to minimise TYR formation was demonstrated. Decreased conversion of HPPA to HPLA, relative to TYR, seems to be most influential in determining the degree of tyrosinaemia.
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25
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Lock EA. The Discovery of the Mode of Action of Nitisinone. Metabolites 2022; 12:metabo12100902. [PMID: 36295804 PMCID: PMC9609752 DOI: 10.3390/metabo12100902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/21/2022] [Accepted: 09/23/2022] [Indexed: 11/29/2022] Open
Abstract
This review briefly discusses the discovery of the mode of action of the triketone herbicide, 2-(2-nitro-4-trifluormethylbenzoyl)-1,3-cyclohexanedione and its use as a drug Nitisinone for the treatment of inborn errors of tyrosine metabolism. Nitisinone is a potent reversible tight-binding inhibitor of the enzyme 4-hydroxyphenylpyruvate dioxygenase, involved in the catabolism of the amino acid tyrosine. Nitisinone is used to treat the rare disease hereditary tyrosinaemia type 1 where the last enzyme in the breakdown of tyrosine, fumarylacetoacetase is deficient. Nitisinone is also used to treat patients with alkaptonuria where the enzyme homogentisic acid oxidase is deficient. Articles in this issue discuss metabolites of tyrosine catabolism in healthy patients and those with alkaptonuria.
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Affiliation(s)
- Edward A Lock
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Byrom Street, Liverpool L3 3AF, UK
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26
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del Álamo M, Bührer C, Fisher D, Griese M, Lingor P, Palladini G, Sireau N, Hivert V, Sangiorgi L, Guillot F, Halftermeyer J, Soucková L, Nosková K, Demlová R. Identifying obstacles hindering the conduct of academic-sponsored trials for drug repurposing on rare-diseases: an analysis of six use cases. Trials 2022; 23:783. [PMID: 36109818 PMCID: PMC9479412 DOI: 10.1186/s13063-022-06713-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 09/03/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Academic-sponsored trials for rare diseases face many challenges; the present paper identifies hurdles in the set-up of six multinational clinical trials for drug repurposing, as use cases.
Methods
Six academic-sponsored multinational trials aiming to generate knowledge on rare diseases drug repurposing were used as examples to identify problems in their set-up. Coordinating investigators leading these trials provided feedback on hurdles linked to study, country, and site set up, on the basis of pre-identified categories established through the analysis of previous peer-reviewed publications.
Results
Administrative burden and lack of harmonization for trial-site agreements were deemed as a major hurdle. Other main identified obstacles included the following: (1) complexity and restriction on the use of public funding, especially in a multinational set up, (2) drug supply, including procurement tendering rules and country-specific requirements for drug stability, and (3) lack of harmonization on regulatory requirements to get trial approvals.
Conclusion
A better knowledge of the non-commercial clinical research landscape and its challenges and requirements is needed to make drugs—especially those with less commercial gain—accessible to rare diseases patients. Better information about existing resources like research infrastructures, clinical research programs, and counseling mechanisms is needed to support and guide clinicians through the many challenges associated to the set-up of academic-sponsored multinational trials.
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27
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Abklärung von blutigem Urin. Monatsschr Kinderheilkd 2022. [DOI: 10.1007/s00112-021-01297-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
ZusammenfassungEin 3‑jähriges Mädchen wird in der pädiatrischen Stoffwechselambulanz vorgestellt, da seit einigen Monaten im Rahmen der Sauberkeitsentwicklung dunkle Urinverfärbungen aufgefallen sind. Die ausführliche Abklärung bezüglich einer Porphyrie und Hämaturie führte nicht zur Diagnosestellung. Die beim Kinderarzt abgegebenen Urinproben waren jeweils unauffällig. Im Rahmen der spezifischen Diagnostik zeigten sich eine erhöhte Homogentisatausscheidung im Urin und damit die Diagnosestellung einer Alkaptonurie. Es wurde eine spezifische Therapie eingeleitet, um Gelenkschädigungen durch pathologische Ablagerungen zu reduzieren. Die weitere Prognose bleibt unklar.
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28
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Comparing the Phenylalanine/Tyrosine Pathway and Related Factors between Keratopathy and No-Keratopathy Groups as Well as between Genders in Alkaptonuria during Nitisinone Treatment. Metabolites 2022; 12:metabo12080772. [PMID: 36005644 PMCID: PMC9416442 DOI: 10.3390/metabo12080772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/11/2022] [Accepted: 08/17/2022] [Indexed: 11/17/2022] Open
Abstract
Nitisinone (NIT) causes tyrosinaemia and corneal keratopathy (KP), especially in men. However, the adaptation within the phenylalanine (PHE)/tyrosine (TYR) catabolic pathway during KP is not understood. The objective of this study is to assess potential differences in the PHE/TYR pathway during KP and the influence of gender in NIT-induced tyrosinaemia in alkaptonuria (AKU). Samples of serum and 24 h urine collected from patients treated with NIT during a 4-year randomized study in NIT vs. no-treatment controls (SONIA 2; Suitability Of Nitisinone In Alkaptonuria 2; EudraCT no. 2013-001633-41) at months 3 (V2), 12 (V3), 24 (V4), 36 (V5) and 48 (V6) were included in these analyses. Homogentisic acid (HGA), TYR, PHE, hydroxyphenylpyruvate (HPPA), hydroxyphenyllactate (HPLA) and sNIT were analysed at all time-points in serum and urine in the NIT-group. All statistical analyses were post hoc. Keratopathy occurred in 10 out of 69 AKU patients, eight of them male. Thirty-five sampling points (serum and 24 h urine) were analysed in patients experiencing KP and 272 in those with no-KP (NKP) during NIT therapy. The KP group had a lower HPLA/TYR ratio and a higher TYR/PHE ratio compared with the NKP group (p < 0.05 for both). There were 24, 45, 100 and 207 sampling points (serum and 24 h urine) in the NIT group which were pre-NIT female, pre-NIT male, NIT female and NIT male, respectively. The PHE/TYR ratio and the HPLA/TYR ratio were lower in males (p < 0.001 and p < 0.01, respectively). In the KP group and in the male group during NIT therapy, adaptive responses to minimise TYR formation were impaired compared to NKP group and females, respectively.
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Abbas K, Basit J, Rehman MEU. Adequacy of nitisinone for the management of alkaptonuria. Ann Med Surg (Lond) 2022; 80:104340. [PMID: 36045846 PMCID: PMC9422360 DOI: 10.1016/j.amsu.2022.104340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 07/28/2022] [Accepted: 07/31/2022] [Indexed: 11/24/2022] Open
Abstract
Alkaptonuria is a rare hereditary disease with a defective enzyme that results in increased homogentisic acid levels in the body. Homogentisic acid accumulates in multiple body parts and initializes tissue damage. Clinical manifestations such as pigmentation of the skin areas and joint destruction result in ochronosis. Nitisinone decreases serum and urinary homogentisic acid levels, improving morbidity by preventing and slowing the progression of alkaptonuria. Nitisinone-induced hypertyrosinemia causes keratopathy and mental ill effects, which can be managed by diet restriction and regular check-ups. A personalized approach is required for treatment by nitisinone. Low-dose oral nitisinone is associated with overall good results and a better safety profile.
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Bozaci AE, Yazici H, Canda E, Uçar SK, Guvenc MS, Berdeli A, Habif S, Coker M. Long-term follow-up of alkaptonuria patients: single center experience. J Pediatr Endocrinol Metab 2022; 35:913-923. [PMID: 35671204 DOI: 10.1515/jpem-2022-0004] [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: 01/02/2022] [Accepted: 05/05/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Alkaptonuria is a rare autosomal recessive genetic disorder resulting from the deficiency of homogentisate 1,2 dioxygenase (HGD), the third enzyme in the tyrosine degradation pathway. Homogentisic acid produced in excess oxidizes into ochronotic pigment polymer. Accumulation of this pigment in various tissues leads to systemic disease. METHODS Clinical, laboratory, molecular findings and treatment characteristics of 35 patients followed up in Ege University Pediatric Nutrition, and Metabolism Department with the diagnosis of alkaptonuria were evaluated retrospectively. RESULTS Twenty-four males (68.57%) and 11 females (31.42%) with a confirmed diagnosis of alkaptonuria from 32 different families were included in the study. We identified 11 different genetic variants; six of these were novel. c.1033C>T, c.676G>A, c.664G>A, c.731_734del, c.1009G>T, c.859_862delins ATAC were not previously reported in the literature. 24 (68.57%) patients only adhered to a low-protein diet in our study group. Seven (20%) patients initiated a low protein diet and NTBC therapy. Mean urinary HGA decreased by 88.7% with nitisinone. No statistical changes were detected in urinary HGA excretion with the low protein diet group. CONCLUSIONS In our study, alkaptonuria patients were diagnosed at different ages, from infancy to adulthood, and progressed with other systemic involvement in the follow-up. Since the initial period is asymptomatic, giving potentially effective treatment from an early age is under discussion. Raising disease awareness is very important in reducing disease mortality and morbidity rates.
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Affiliation(s)
- Ayse Ergul Bozaci
- Department of Pediatrics, Ege University Faculty of Medicine, Division of Pediatric Metabolism, Izmir, Turkey
| | - Havva Yazici
- Department of Pediatrics, Ege University Faculty of Medicine, Division of Pediatric Metabolism, Izmir, Turkey
| | - Ebru Canda
- Department of Pediatrics, Ege University Faculty of Medicine, Division of Pediatric Metabolism, Izmir, Turkey
| | - Sema Kalkan Uçar
- Department of Pediatrics, Ege University Faculty of Medicine, Division of Pediatric Metabolism, Izmir, Turkey
| | - Merve Saka Guvenc
- Department of Medical Genetics, Tepecik Research and Training Hospital, Izmir, Turkey
| | - Afig Berdeli
- Department of Molculer Genetics, Ege University Faculty of Medicine, Izmir, Turkey
| | - Sara Habif
- Department of Biochemistry, Ege University Faculty of Medicine, Izmir, Turkey
| | - Mahmut Coker
- Department of Pediatrics, Ege University Faculty of Medicine, Division of Pediatric Metabolism, Izmir, Turkey
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Norman BP, Davison AS, Hughes JH, Sutherland H, Wilson PJ, Berry NG, Hughes AT, Milan AM, Jarvis JC, Roberts NB, Ranganath LR, Bou-Gharios G, Gallagher JA. Metabolomic studies in the inborn error of metabolism alkaptonuria reveal new biotransformations in tyrosine metabolism. Genes Dis 2022; 9:1129-1142. [PMID: 35685462 PMCID: PMC9170613 DOI: 10.1016/j.gendis.2021.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/13/2021] [Accepted: 02/10/2021] [Indexed: 02/07/2023] Open
Abstract
Alkaptonuria (AKU) is an inherited disorder of tyrosine metabolism caused by lack of active enzyme homogentisate 1,2-dioxygenase (HGD). The primary consequence of HGD deficiency is increased circulating homogentisic acid (HGA), the main agent in the pathology of AKU disease. Here we report the first metabolomic analysis of AKU homozygous Hgd knockout (Hgd -/-) mice to model the wider metabolic effects of Hgd deletion and the implication for AKU in humans. Untargeted metabolic profiling was performed on urine from Hgd -/- AKU (n = 15) and Hgd +/- non-AKU control (n = 14) mice by liquid chromatography high-resolution time-of-flight mass spectrometry (Experiment 1). The metabolites showing alteration in Hgd -/- were further investigated in AKU mice (n = 18) and patients from the UK National AKU Centre (n = 25) at baseline and after treatment with the HGA-lowering agent nitisinone (Experiment 2). A metabolic flux experiment was carried out after administration of 13C-labelled HGA to Hgd -/-(n = 4) and Hgd +/-(n = 4) mice (Experiment 3) to confirm direct association with HGA. Hgd -/- mice showed the expected increase in HGA, together with unexpected alterations in tyrosine, purine and TCA-cycle pathways. Metabolites with the greatest abundance increases in Hgd -/- were HGA and previously unreported sulfate and glucuronide HGA conjugates, these were decreased in mice and patients on nitisinone and shown to be products from HGA by the 13C-labelled HGA tracer. Our findings reveal that increased HGA in AKU undergoes further metabolism by mainly phase II biotransformations. The data advance our understanding of overall tyrosine metabolism, demonstrating how specific metabolic conditions can elucidate hitherto undiscovered pathways in biochemistry and metabolism.
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Key Words
- AKU, alkaptonuria
- AMRT, accurate mass/retention time
- Alkaptonuria
- Biotransformation
- CV, coefficient of variation
- FC, fold change
- FDR, false-discovery rate
- HGA, homogentisic acid
- HGD, homogentisate 1,2-dioxygenase
- HPPD, hydroxyphenylpyruvic acid dioxygenase
- LC-QTOF-MS, liquid chromatography quadrupole time-of-flight mass spectrometry
- MS/MS, tandem mass spectrometry
- MSC, Molecular Structure Correlator
- Metabolism
- Metabolomics
- Mice
- PCA, principal component analysis
- QC, quality control
- RT, retention time
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Affiliation(s)
- Brendan P Norman
- Institute of Life Course and Medical Sciences, University of Liverpool, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
| | - Andrew S Davison
- Department of Clinical Biochemistry & Metabolic Medicine, Liverpool Clinical Laboratories, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK
| | - Juliette H Hughes
- Institute of Life Course and Medical Sciences, University of Liverpool, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
| | - Hazel Sutherland
- Institute of Life Course and Medical Sciences, University of Liverpool, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK.,School of Sport & Exercise Sciences, Liverpool John Moores University, Tom Reilly Building, Byrom Street, Liverpool, L3 3AF, UK
| | - Peter Jm Wilson
- Institute of Life Course and Medical Sciences, University of Liverpool, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
| | - Neil G Berry
- Department of Chemistry, University of Liverpool, Crown Street, Liverpool, L69 7ZD, UK
| | - Andrew T Hughes
- Department of Clinical Biochemistry & Metabolic Medicine, Liverpool Clinical Laboratories, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK
| | - Anna M Milan
- Department of Clinical Biochemistry & Metabolic Medicine, Liverpool Clinical Laboratories, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK
| | - Jonathan C Jarvis
- School of Sport & Exercise Sciences, Liverpool John Moores University, Tom Reilly Building, Byrom Street, Liverpool, L3 3AF, UK
| | - Norman B Roberts
- Institute of Life Course and Medical Sciences, University of Liverpool, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
| | - Lakshminarayan R Ranganath
- Department of Clinical Biochemistry & Metabolic Medicine, Liverpool Clinical Laboratories, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK
| | - George Bou-Gharios
- Institute of Life Course and Medical Sciences, University of Liverpool, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
| | - James A Gallagher
- Institute of Life Course and Medical Sciences, University of Liverpool, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
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Ranganath LR, Hughes AT, Davison AS, Khedr M, Olsson B, Rudebeck M, Imrich R, Norman BP, Bou-Gharios G, Gallagher JA, Milan AM. Temporal adaptations in the phenylalanine/tyrosine pathway and related factors during nitisinone-induced tyrosinaemia in alkaptonuria. Mol Genet Metab 2022:S1096-7192(22)00325-0. [PMID: 35680516 DOI: 10.1016/j.ymgme.2022.05.006] [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: 04/20/2022] [Revised: 05/21/2022] [Accepted: 05/28/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Adaptations within the phenylalanine (PHE)/tyrosine (TYR) pathway during nitisinone (NIT) are not fully understood. OBJECTIVE To characterise the temporal changes in metabolic features in NIT-treated patients with alkaptonuria. PATIENTS AND METHODS Serum (s) and 24-urine (u) homogentisic acid (sHGA, uHGA24), TYR (sTYR, uTYR24), PHE (sPHE, uPHE24), hydroxyphenylpyruvate (sHPPA, uHPPA24), hydroxyphenyllactate (sHPLA, uHPLA24) and sNIT were measured at baseline (V1) and until month 48 (V6) in 69 NIT-treated patients, recommended to reduce protein intake. The 24-h urine urea (uUREA24), creatinine (uCREAT24) and body weight were also measured. Amounts of tyrosine metabolites in total body water (TBW) were derived by multiplying the serum concentrations by 60% body weight, and sum of TBW and urine metabolites resulted in combined values (c). RESULTS uUREA24 and uCREAT24 decreased between V1 and V6 during NIT, whereas body weight and sNIT increased. Linear regression coefficient between uUREA24 and uCREAT24 was extremely strong (R = 0.84). sPHE, TBWPHE and cPHE24 increased gradually from V1 to V6. A decrease in cTYR24/cPHE24, sTYR/sPHE and TBWTYR/TBWPHE was seen from V2 to V6. Serum, 24-urine and combined TYR, HPPA and HPLA either remained stable or decreased from V2 to V6. DISCUSSION The gradual increase in PHE suggests adaptation to increasing TYR during NIT therapy. The decrease in protein intake resulted in decreased muscle mass and increased weight gain. CONCLUSION Progressive adaptation by decreasing PHE conversion to TYR occurs over time during NIT therapy. A low protein diet results in loss of muscle mass but also weight gain suggesting an increase in fat mass.
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Affiliation(s)
- L R Ranganath
- Departments of Clinical Biochemistry and Metabolic Medicine, Liverpool University Hospitals NHS Foundation Trusts, UK; Musculoskeletal & Ageing Science, Institute of Life Course & Medical Sciences, University of Liverpool, UK.
| | - A T Hughes
- Departments of Clinical Biochemistry and Metabolic Medicine, Liverpool University Hospitals NHS Foundation Trusts, UK
| | - A S Davison
- Departments of Clinical Biochemistry and Metabolic Medicine, Liverpool University Hospitals NHS Foundation Trusts, UK
| | - M Khedr
- Departments of Clinical Biochemistry and Metabolic Medicine, Liverpool University Hospitals NHS Foundation Trusts, UK
| | | | | | - R Imrich
- National Institute of Rheumatic Diseases, Piešťany, Slovakia; Biomedical Research Centre, Slovak Academy of Sciences, Bratislava, Slovakia
| | - B P Norman
- Musculoskeletal & Ageing Science, Institute of Life Course & Medical Sciences, University of Liverpool, UK
| | - G Bou-Gharios
- Musculoskeletal & Ageing Science, Institute of Life Course & Medical Sciences, University of Liverpool, UK
| | - J A Gallagher
- Musculoskeletal & Ageing Science, Institute of Life Course & Medical Sciences, University of Liverpool, UK
| | - A M Milan
- Departments of Clinical Biochemistry and Metabolic Medicine, Liverpool University Hospitals NHS Foundation Trusts, UK; Musculoskeletal & Ageing Science, Institute of Life Course & Medical Sciences, University of Liverpool, UK
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Mahdkhah A, Salehpour F, Lotfinia I, Riazi A, Mirzaee F, Kaleibar SA. Asymptomatic alkaptonuria and degenerative disc herniation report of two rare cases. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Impact of Nitisinone on the Cerebrospinal Fluid Metabolome of a Murine Model of Alkaptonuria. Metabolites 2022; 12:metabo12060477. [PMID: 35736410 PMCID: PMC9230570 DOI: 10.3390/metabo12060477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 05/18/2022] [Accepted: 05/20/2022] [Indexed: 02/01/2023] Open
Abstract
Background: Nitisinone-induced hypertyrosinaemia is well documented in Alkaptonuria (AKU), and there is uncertainty over whether it may contribute to a decline in cognitive function and/or mood by altering neurotransmitter metabolism. The aim of this work was to evaluate the impact of nitisinone on the cerebrospinal fluid (CSF) metabolome in a murine model of AKU, with a view to providing additional insight into metabolic changes that occur following treatment with nitisinone. Methods: 17 CSF samples were collected from BALB/c Hgd−/− mice (n = 8, treated with nitisinone—4 mg/L and n = 9, no treatment). Samples were diluted 1:1 with deionised water and analysed using a 1290 Infinity II liquid chromatography system coupled to a 6550 quadrupole time-of-flight mass spectrometry (Agilent, Cheadle, UK). Raw data were processed using a targeted feature extraction algorithm and an established in-house accurate mass retention time database. Matched entities (±10 ppm theoretical accurate mass and ±0.3 min retention time window) were filtered based on their frequency and variability. Experimental groups were compared using a moderated t-test with Benjamini−Hochberg false-discovery rate adjustment. Results: L-Tyrosine, N-acetyl-L-tyrosine, γ-glutamyl-L-tyrosine, p-hydroxyphenylacetic acid, and 3-(4-hydroxyphenyl)lactic acid were shown to increase in abundance (log2 fold change 2.6−6.9, 3/5 were significant p < 0.05) in the mice that received nitisinone. Several other metabolites of interest were matched, but no significant differences were observed, including the aromatic amino acids phenylalanine and tryptophan, and monoamine metabolites adrenaline, 3-methoxy-4-hydroxyphenylglycol, and octopamine. Conclusions: Evaluation of the CSF metabolome of a murine model of AKU revealed a significant increase in the abundance of a limited number of metabolites following treatment with nitisinone. Further work is required to understand the significance of these findings and the mechanisms by which the altered metabolite abundances occur.
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Dewan K, MacDonald CB, Shires CB. Blue man: Ochronosis in Otolaryngology. Clin Case Rep 2022; 10:e05717. [PMID: 35441025 PMCID: PMC9012831 DOI: 10.1002/ccr3.5717] [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: 12/27/2021] [Revised: 03/21/2022] [Accepted: 03/28/2022] [Indexed: 11/06/2022] Open
Abstract
Blue discoloration of the skin and cartilage, or ochronosis, is a rare physical examination finding. We present two cases of childhood onset ochronosis, one exogenous and one endogenous in etiology. The first was caused by minocycline use for severe acne, and the second was caused by congenital alkaptonuria.
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Affiliation(s)
- Karuna Dewan
- Division of Laryngology Otolaryngology – Head and Neck Surgery Louisiana State University Shreveport Louisiana USA
| | - Charles Bruce MacDonald
- Department of Otolaryngology – Head and Neck Surgery University of Tennessee Health Science Center Memphis Tennessee USA
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Ahmad MSZ, Ahmed M, Khedr M, Borgia A, Madden A, Ranganath LR, Kaye S. Association of alkaptonuria and low dose nitisinone therapy with cataract formation in a large cohort of patients. JIMD Rep 2022; 63:351-360. [PMID: 35822094 PMCID: PMC9259401 DOI: 10.1002/jmd2.12288] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 12/23/2022] Open
Abstract
Homogentisic acid (HGA) lowering, disease modifying off‐label nitisinone therapy has been used in the United Kingdom National Alkaptonuria Centre (NAC) since 2012. This study evaluated the serendipitous observation of cataract in a large cohort of patients with the very rare disease alkaptonuria (AKU), over a 5‐year period. Patients with AKU who attended the NAC since 2012. Standard physical examination and ocular assessment, including photographs of the crystalline lens were taken before commencement of nitisinone 2 mg daily and annually over 5 years. Photographs were randomised and graded by two independent observers using the WHO cataract classification. AKU patients who did not receive nitisinone were included as a control group. HGA was measured on acidified 24 h urine (u‐HGA24) and HGA and tyrosine in fasting acidified serum samples (sHGA, sTYR) at each visit. Patients without suitable lens images were excluded. Cataract (mean grade 1) was noted at baseline in 47 out of 62 (76%) with a mean (SD) age of 44 (14) years. In nitisinone‐treated patients, there were significant increases in the mean grade of nuclear (0.18, p < 0.01) and cortical (0.38, p < 0.01) lens opacities over the mean duration of 4.93 years of the study. Worsening of the nuclear cataract and cortical lens opacities by at least 1 grade was noted in 14 out of 46 (30%) and 11 out of 46 (24%) patients, respectively. There is an increased prevalence and progression of cataract in AKU and a possible association of nitisinone with cataract progression.
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Affiliation(s)
| | - Mahmoud Ahmed
- Department of Ophthalmology Royal Liverpool University Hospital Liverpool UK
| | - Milad Khedr
- Clinical Biochemistry and Metabolic Medicine Royal Liverpool University Hospital Liverpool UK
| | - Alfredo Borgia
- Department of Ophthalmology Royal Liverpool University Hospital Liverpool UK
| | - Andrea Madden
- Department of Ophthalmology Royal Liverpool University Hospital Liverpool UK
| | | | - Stephen Kaye
- Department of Ophthalmology Royal Liverpool University Hospital Liverpool UK
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Hughes AT, Milan AM, Shweihdi E, Gallagher J, Ranganath L. Method development and validation for analysis of phenylalanine, 4‐hydroxyphenyllactic acid and 4‐hydroxyphenylpyruvic acid in serum and urine. JIMD Rep 2022; 63:341-350. [PMID: 35822095 PMCID: PMC9259389 DOI: 10.1002/jmd2.12287] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/22/2022] [Accepted: 03/23/2022] [Indexed: 12/28/2022] Open
Abstract
Alkaptonuria (AKU) is a rare debilitating autosomal recessive disorder of tyrosine (TYR) metabolism which results in a deficiency of the enzyme homogentisate 1,2‐dioxygenase activity. Several studies have reported the metabolic changes in homogentisic acid (HGA) concentrations and subsequent deposition of an ochronotic pigment in connective tissues, especially cartilage. Treatment with nitisinone (NTBC) reduces urinary and circulating HGA, but its mode of action results in hypertyrosinaemia. The effect of NTBC on other metabolites in the TYR pathway has not been reported. Modification of the current reverse phase liquid chromatography tandem mass spectrometry methods for serum and urine to include phenylalanine (PHE), hydroxyphenyllactate (HPLA) and hydroxyphenylpyruvate (HPPA) has been validated. HPPA and HPLA (negative ionisation) eluted at 2.8 and 2.9 min respectively on an Atlantis C18 column with PHE (positive ionisation) eluting earlier at 2.4 min. Intra‐ and inter‐assay accuracy was between 96.3% and 100.3% for PHE; 96.6% and 110.5% for HPLA and 95.0% and 107.8% for HPPA in both urine and serum. Precision, both inter‐ and intra‐assay, was <10% for all analytes in both serum and urine. No significant issues with carry‐over, stability or matrix interferences were seen in either the urine or serum assays. Measurement of serum and urine from AKU patients has demonstrated a robust, fully validated assay, appropriate for monitoring of patients with AKU and for demonstrating metabolite changes, following NTBC therapy.
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Affiliation(s)
- Andrew T. Hughes
- Department of Clinical Biochemistry and Metabolic Medicine Liverpool University Hospitals NHS Foundation Trusts Liverpool UK
- Bone and Joint Research Group, Musculoskeletal Biology The University of Liverpool Liverpool UK
| | - Anna M. Milan
- Department of Clinical Biochemistry and Metabolic Medicine Liverpool University Hospitals NHS Foundation Trusts Liverpool UK
- Bone and Joint Research Group, Musculoskeletal Biology The University of Liverpool Liverpool UK
| | - Ella Shweihdi
- Department of Clinical Biochemistry and Metabolic Medicine Liverpool University Hospitals NHS Foundation Trusts Liverpool UK
| | - James Gallagher
- Department of Clinical Biochemistry and Metabolic Medicine Liverpool University Hospitals NHS Foundation Trusts Liverpool UK
- Bone and Joint Research Group, Musculoskeletal Biology The University of Liverpool Liverpool UK
| | - Lakshminarayan Ranganath
- Department of Clinical Biochemistry and Metabolic Medicine Liverpool University Hospitals NHS Foundation Trusts Liverpool UK
- Bone and Joint Research Group, Musculoskeletal Biology The University of Liverpool Liverpool UK
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Davison AS, Hughes G, Harrold JA, Clarke P, Griffin R, Ranganath LR. Long‐term low dose nitisinone therapy in adults with alkaptonuria shows no cognitive decline or increased severity of depression. JIMD Rep 2022; 63:221-230. [PMID: 35433173 PMCID: PMC8995840 DOI: 10.1002/jmd2.12272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/10/2022] [Accepted: 01/13/2022] [Indexed: 12/13/2022] Open
Abstract
Little is documented on whether nitisinone‐induced hypertyrosinaemia alters cognitive functioning or leads to worsening depression in alkaptonuria (AKU). Wechsler Adult Intelligence Scale‐IV (WAIS‐IV) and Beck Depression Inventory‐II (BDI‐II) assessments were performed before and annually following treatment with nitisinone 2 mg daily to assess the impact on cognitive functioning and severity of depression. Serum tyrosine concentrations were also measured annually. WAIS‐IV: 63 patients (27 females/36 males: mean age[years] [±standard deviation, range] 55.7[13.7, 26–79]; 60.3[9.6, 19–75]) were included at baseline for assessment of: verbal comprehension (VC), perceptual reasoning (PR), working memory (WM), and processing speed (PS) using separate indices. Over the 6‐year period studied 43, 39, 36, 29, 26 and 15 patients had annual assessments. Using a longitudinal model (age and sex adjusted) no significant differences were observed in any of the indices over this period, apart from VC which showed a significant increase after adjustment for sex (p < 0.05). BDI‐II: 74 patients (32 females/42 males: mean age[years] [±standard deviation, range] 56.1[13.2, 26–79]; 42 males, 51.5[16.3, 19–70]) were included at baseline. Over the 7‐year period studied 48, 47, 38, 34, 32, 24 and 12 patients had annual assessments. No significant differences in BDI‐II scores were observed when compared to baseline. Hypertyrosinaemia was observed in all patients following treatment with nitisinone (p < 0.001, at all annual visits). Serum tyrosine was not correlated with WAIS‐IV sub‐test indices or BDI‐II scores pre‐ or post‐nitisinone therapy. These findings suggest that treatment with nitisinone does not affect cognitive functioning and or lead to increased severity of depression.
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Affiliation(s)
- Andrew S. Davison
- Department of Clinical Biochemistry and Metabolic Medicine, Liverpool Clinical Laboratories Royal Liverpool University Hospital Liverpool UK
| | - Gin Hughes
- Department of Psychology University of Liverpool Liverpool UK
| | | | - Pam Clarke
- Department of Psychology University of Liverpool Liverpool UK
| | - Rebecca Griffin
- Liverpool Cancer Trials Unit University of Liverpool Liverpool UK
| | - Lakshminarayan R. Ranganath
- Department of Clinical Biochemistry and Metabolic Medicine, Liverpool Clinical Laboratories Royal Liverpool University Hospital Liverpool UK
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Ranganath L, Milan A, Hughes A, Davison A, Khedr M, Norman B, Bou-Gharios G, Gallagher J, Gornall M, Jackson R, Imrich R, Rovensky J, Rudebeck M, Olsson B. Characterization of changes in the tyrosine pathway by 24-h profiling during nitisinone treatment in alkaptonuria. Mol Genet Metab Rep 2022; 30:100846. [PMID: 35242577 PMCID: PMC8856922 DOI: 10.1016/j.ymgmr.2022.100846] [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: 01/09/2022] [Revised: 01/19/2022] [Accepted: 01/26/2022] [Indexed: 11/13/2022] Open
Abstract
Background Although changes in the tyrosine pathway during nitisinone therapy are known, a complete characterization of the induced tyrosinaemia is lacking to improve disease management. Patients and methods Our research aims were addressed by 24-h blood sampling. 40 patients with alkaptonuria (AKU), treated with 0, 1, 2, 4 and 8 mg nitisinone daily (n = 8), were studied over four weeks. Serum homogentisic acid (sHGA), tyrosine (sTYR), phenylalanine (sPHE), hydroxyphenylpyruvate (sHPPA), hydroxyphenyllactate (sHPLA) and nitisinone (sNIT) were measured at baseline and after four weeks. Results sNIT showed a clear dose-proportional response. sTYR increased markedly but with less clear-cut dose responses after nitisinone. Fasting and average 24-h (Cav) sTYR responses were similar. Individual patient sTYR 24-h profiles showed significant fluctuations during nitisinone therapy. At week 4, sTYR, sHPPA and sHPPL all showed dose-related increases compared to V0, with the greatest difference between 1 and 8 mg nitisinone seen for HPLA, while there was no change from V0 in sPHE. sHGA decreased to values around the lower limit of quantitation. Discussion There was sustained tyrosinaemia after four weeks of nitisinone therapy with significant fluctuations over the day in individual patients. Diet and degree of conversion of HPPA to HPLA may determine extent of nitisinone-induced tyrosinaemia. Conclusion A fasting blood sample is recommended to monitor sTYR during nitisinone therapy Adaptations in HPPA metabolites as well as the inhibition of tyrosine aminotransferase could be contributing factors generating tyrosinaemia during nitisinone therapy. The tyrosine catabolic pathway is the sole route of disposal of excess dietary phenylalanine and tyrosine Individual patient serum tyrosine 24-h profiles show significant fluctuations especially during nitisinone therapy A fasting serum tyrosine measurement is the preferred choice for monitoring tyrosineamia during nitisinone therapy Meals are key determinants of tyrosinaemia during nitisinone Adaptations in hydroxyphenylpyruvate, hydroxyphenyllactate and tyrosine during nitisinone could determine the extent of tyrosinaemia
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Soltysova A, Kuzin A, Samarkina E, Zatkova A. Alkaptonuria in Russia. Eur J Hum Genet 2022; 30:237-242. [PMID: 34504318 PMCID: PMC8821605 DOI: 10.1038/s41431-021-00955-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/28/2021] [Accepted: 08/19/2021] [Indexed: 02/03/2023] Open
Abstract
Alkaptonuria is characterized by the accumulation of homogentisic acid (HGA), part of which is excreted in the urine but the excess HGA forms a dark brown ochronotic pigment that deposits in the connective tissue (ochronosis), eventually leading to early-onset severe arthropathy. We analyzed a cohort of 48 Russian AKU families by sequencing all 14 exons (including flanking intronic sequences) of the homogentisate 1,2-dioxygenase gene (HGD) and Multiplex Ligation-dependent Probe Amplification (MLPA) analysis. Nine novel likely pathogenic HGD variants were identified, which have not been reported previously in any other country. Recently, Bychkov et al. [1] reported on the variant spectrum in another cohort of 49 Russian AKU patients. Here we summarize complete data from both cohorts that include 82 Russian AKU families. Taken together, 31 different HGD variants were found in these patients, of which 14 are novel and found only in Russia. The most common variant was c.481G>A (p.(Gly161Arg)), present in almost 54% of all AKU alleles.
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Affiliation(s)
- Andrea Soltysova
- grid.419303.c0000 0001 2180 9405Biomedical Research Center, Slovak Academy of Sciences, Bratislava, Slovakia ,grid.7634.60000000109409708Faculty of Natural Sciences, Department of Molecular Biology, Comenius University, Bratislava, Slovakia
| | - Alexandr Kuzin
- grid.488825.bV.A.Nasonova Research Institute of Rheumatology, Moscow, Russia ,grid.465497.dRussian Medical Academy of Continuous Professional Education, Moscow, Russia
| | - Elena Samarkina
- grid.488825.bV.A.Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - Andrea Zatkova
- grid.419303.c0000 0001 2180 9405Biomedical Research Center, Slovak Academy of Sciences, Bratislava, Slovakia
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Altemir A, Bara J, Setó-Torrent N, Salleras-Redonnet M, Morales M. Blue ears: a clue to diagnosis of alkaptonuria identified via telemedicine consultation. Clin Exp Dermatol 2022; 47:806-808. [PMID: 34984686 DOI: 10.1111/ced.15056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2021] [Indexed: 11/28/2022]
Abstract
Alkaptonuria is a rare autosomal recessive metabolic disorder with wide systemic involvement including pigment deposition. We present an unusual case diagnosed by an image obtained via telemedicine showing pigment deposition in the earlobe. We highlight how this clue may allow prompt diagnosis of alkaptonuria and prevent disease progression.
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Affiliation(s)
- Arcadi Altemir
- Department of Dermatology, Hospital Universitari Sagrat Cor, Grupo Hospitalario Quirónsalud, Barcelona, Spain
| | - Javier Bara
- Maxillofacial Institute, Hospital Universitari Sagrat Cor, Grupo Hospitalario Quirónsalud, Barcelona, Spain
| | - Núria Setó-Torrent
- Department of Dermatology, Hospital Universitari Sagrat Cor, Grupo Hospitalario Quirónsalud, Barcelona, Spain
| | - Montse Salleras-Redonnet
- Department of Dermatology, Hospital Universitari Sagrat Cor, Grupo Hospitalario Quirónsalud, Barcelona, Spain
| | - Montserrat Morales
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Madrid, Spain
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Olsson B, Ranganath L, Arnoux J, Imrich R, Milan A, Rudebeck M. Effects of a protein-restricted diet on body weight and serum tyrosine concentrations in patients with alkaptonuria. JIMD Rep 2022; 63:41-49. [PMID: 35028270 PMCID: PMC8743336 DOI: 10.1002/jmd2.12255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/26/2021] [Accepted: 10/11/2021] [Indexed: 01/16/2023] Open
Abstract
In an open-label, controlled study of nitisinone in alkaptonuria (SONIA 2), patients were advised to lower dietary protein intake to reduce serum tyrosine (s-Tyr) levels and the risk of keratopathy. A body weight increase was observed in the nitisinone-treated patients but not in the control group. To investigate the effectiveness and consequence of protein restriction in patients with alkaptonuria, a post-hoc analysis of SONIA 2 was performed. One hundred and thirty-eight patients were randomised (nitisinone: n = 69, controls: n = 69). Comparison of baseline and Month 12 data on 24-h urinary excretion of HGA (u-HGA24) and urea (u-urea24, used as an approximate protein intake measure), tyrosine and body weight were performed using paired t tests. Comparisons of data between groups were made using 2-sample t tests. We found that u-urea24 decreased more in nitisinone-treated than controls. The study centre with lowest average s-Tyr and u-urea24 (nitisinone arm) at Month 12 also had lowest keratopathy incidence (3.1%), while the centre with highest values showed the highest (14.6%). S-Tyr was generally high in those with keratopathy, but those without keratopathy had similar elevated values. A similar pattern across centres was seen for body weight changes, with a statistically significant weight increase in nitisinone-treated patients at centres with lower u-urea24 values. Therefore, in nitisinone-treated patients, protein restriction led to increased body weight but may also have lowered the risk of developing keratopathies. If introduced, a protein-restricted diet should be supervised by a dietician and, when appropriate, include amino acid supplements deficient in tyrosine and phenylalanine, to avoid malnutrition and undesired weight increase.
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Affiliation(s)
| | - Lakshminarayan Ranganath
- Institute of Ageing & Chronic DiseaseUniversity of LiverpoolLiverpoolUK
- Departments of Clinical Biochemistry and Metabolic MedicineLiverpool University Hospitals NHS Foundation Trust (LUH)LiverpoolUK
| | | | - Richard Imrich
- Institute of Clinical and Translational Research, Biomedical Research Center, Slovak Academy of SciencesBratislavaSlovakia
- National Institute of Rheumatic DiseasesPiešťanySlovakia
| | - Anna Milan
- Departments of Clinical Biochemistry and Metabolic MedicineLiverpool University Hospitals NHS Foundation Trust (LUH)LiverpoolUK
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43
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Ranganath LR, Milan AM, Hughes AT, Khedr M, Norman BP, Alsbou M, Imrich R, Gornall M, Sireau N, Gallagher JA, Jackson R. Comparing nitisinone 2 mg and 10 mg in the treatment of alkaptonuria-An approach using statistical modelling. JIMD Rep 2022; 63:80-92. [PMID: 35028273 PMCID: PMC8743340 DOI: 10.1002/jmd2.12261] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/04/2021] [Accepted: 10/25/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Outcomes from studies employing nitisinone 10 mg and 2 mg in alkaptonuria were compared. PATIENTS AND METHODS Sixty-nine patients in each of the nitisinone (10 mg daily) and controls of suitability of nitisinone in alkaptonuria 2 (SONIA 2), as well as 37 and 23 in nitisinone (2 mg daily) and control cohorts at the National Alkaptonuria Centre (NAC), respectively, were followed up for 4 years. Severity of alkaptonuria (AKU) was assessed by the AKU Severity Score Index (AKUSSI). 24-h urine homogentisic acid (uHGA24), serum HGA (sHGA), serum tyrosine (sTYR) and serum nitisinone (sNIT) were also analysed at each time point. Dietetic support was used in the NAC, but not in SONIA 2. Safety outcomes were also compared. All statistical analyses were post hoc. RESULTS The slope of the AKUSSI was 0.55, 0.19, 0.30, and 0.06 per month in the control NAC, nitisinone NAC, control SONIA 2, and nitisinone SONIA 2 cohorts, respectively. The intersection of the slopes on the x-axis was -132, -411, -295, and - 1460 months, respectively. The control and nitisinone slope comparisons were statistically significant both in the NAC (p < 0.001) and the SONIA 2 (p < 0.001). Corneal keratopathy occurred in 3 and 10 patients in the NAC and SONIA 2, respectively. DISCUSSION The nitisinone 10 mg dose decreased disease progression more than the 2 mg dose although the incidence of corneal keratopathy was 14.5% and 4.9%, respectively. CONCLUSION Nitisinone 10 mg decreased urine and serum HGA, increased serum tyrosine, and decreased disease progression more than 2 mg. Low-protein dietetic support may be needed to mitigate tyrosinaemia following nitisinone. HIGHLIGHTS Nitisinone 10 mg apparently slows alkaptonuria disease progression more than 2 mg in adults.Corneal keratopathy during nitisinone therapy was more common in men.Serum nitisinone concentrations increased significantly over time.Nitisinone may inhibit cytochrome P450 self catabolism.
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Affiliation(s)
- Lakshminarayan R. Ranganath
- Departments of Clinical Biochemistry and Metabolic MedicineLiverpool University Hospitals NHS Foundation TrustsLiverpoolUK
- Musculoskeletal Biology and AgeingUniversity of Liverpool, William Henry Duncan BuildingLiverpoolUK
| | - Anna M. Milan
- Departments of Clinical Biochemistry and Metabolic MedicineLiverpool University Hospitals NHS Foundation TrustsLiverpoolUK
- Musculoskeletal Biology and AgeingUniversity of Liverpool, William Henry Duncan BuildingLiverpoolUK
| | - Andrew T. Hughes
- Departments of Clinical Biochemistry and Metabolic MedicineLiverpool University Hospitals NHS Foundation TrustsLiverpoolUK
- Musculoskeletal Biology and AgeingUniversity of Liverpool, William Henry Duncan BuildingLiverpoolUK
| | - Milad Khedr
- Departments of Clinical Biochemistry and Metabolic MedicineLiverpool University Hospitals NHS Foundation TrustsLiverpoolUK
| | - Brendan P. Norman
- Musculoskeletal Biology and AgeingUniversity of Liverpool, William Henry Duncan BuildingLiverpoolUK
| | | | - Richard Imrich
- National Institute of Rheumatic DiseasesPiešťanySlovakia
- Biomedical Research Center, Slovak Academy of SciencesBratislavaSlovakia
| | - Matthew Gornall
- Liverpool Cancer Trials UnitUniversity of LiverpoolLiverpoolUK
| | | | - James A. Gallagher
- Musculoskeletal Biology and AgeingUniversity of Liverpool, William Henry Duncan BuildingLiverpoolUK
| | - Richard Jackson
- Liverpool Cancer Trials UnitUniversity of LiverpoolLiverpoolUK
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Ranganath LR, Khedr M, Mistry A, Vinjamuri S, Gallagher JA. Treatment of osteoporotic fractures in alkaptonuria by teriparatide stimulates bone formation and decreases fracture rate - A report of two cases. Bone Rep 2021; 15:101151. [PMID: 34926730 PMCID: PMC8649650 DOI: 10.1016/j.bonr.2021.101151] [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: 08/31/2021] [Revised: 11/09/2021] [Accepted: 11/15/2021] [Indexed: 11/29/2022] Open
Abstract
Two cases of advanced alkaptonuria (AKU) with co-existing osteoporosis are described. Case 1 developed multiple non-vertebral fragility fractures, while Case 2 developed vertebral fragility fractures, both refractory to bisphosphonates. Difficulties in diagnosing osteoporosis in AKU complicated by extensive calcifying and ossifying spondylosis are discussed. Both patients continued to fracture despite nitisinone therapy for metabolic control of AKU, as well as bisphosphonate antiresorptive therapy for osteoporosis. Subsequently the patients were treated with teriparatide 20 μg subcutaneous injections daily for two years, leading to reduction in fractures soon after commencing therapy in both cases. Markers of bone remodelling P1NP and CTX were stimulated. No complications due hypercalcaemia or calcification were encountered in either case. We conclude that teriparatide is an effective adjunct in the treatment of AKU when bisphosphonates prove ineffective. Two case of osteoporosis are described in patients with the ultra-rare genetic disorder, Alkaptonuria (AKU) Diagnosis of osteoporosis in AKU is complicated by extensive calcifying and ossifying spondylosis Treatment of AKU with Nitisinone and or antiresorptive did not improve bone health in these patients Teriparatide led to a reduction in fractures and is an effective adjunct in AKU when bisphosphonates prove ineffective
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Affiliation(s)
- L R Ranganath
- Department of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool University Hospital, Prescot Street, Liverpool L7 8XP, United Kingdom.,IACD, University of Liverpool, William Henry Duncan Building, West Derby Street, Liverpool L7 8TX, United Kingdom
| | - M Khedr
- Department of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool University Hospital, Prescot Street, Liverpool L7 8XP, United Kingdom
| | - A Mistry
- Department of Radiology, Royal Liverpool University Hospital, Prescot Street, Liverpool L7 8XP, United Kingdom
| | - S Vinjamuri
- Department of Nuclear Medicine, Royal Liverpool University Hospital, Prescot Street, Liverpool L7 8XP, United Kingdom
| | - J A Gallagher
- IACD, University of Liverpool, William Henry Duncan Building, West Derby Street, Liverpool L7 8TX, United Kingdom
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45
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Rudebeck M, Scott C, Rhodes NP, van Kan C, Olsson B, Al-Sbou M, Hall AK, Sireau N, Ranganath LR. Clinical development innovation in rare diseases: lessons learned and best practices from the DevelopAKUre consortium. Orphanet J Rare Dis 2021; 16:510. [PMID: 34906169 PMCID: PMC8670024 DOI: 10.1186/s13023-021-02137-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 11/28/2021] [Indexed: 11/30/2022] Open
Abstract
New opportunities have arisen for development of therapies for rare diseases with the increased focus and progress in the field. However, standardised framework integrating individual initiatives has not been formed. We present lessons learned and best practice from a collaborative success case in developing a treatment for a rare genetic disease. Our unique consortium model incorporated several of the identified developments under one project, DevelopAKUre, truly bringing together academia, industry and patient organisations in clinical drug development. We found that the equal partnership between all parties in our consortium was a key success factor creating a momentum based on a strong organisational culture where all partners had high engagement and taking ownership of the entire programme. With an agreed mutual objective, this provided synergies through connecting the strengths of the individual parties. Another key success factor was the central role of the patient organisation within the management team, and their unique study participants’ advocacy role securing the understanding and meeting the needs of the clinical study participants in real-time. This resulted in an accelerated enrolment into the clinical studies with a high retention rate allowing for delivery of the programme with significantly improved timelines. Our project was partly funded through an external EU research grant, enabling our model with equal partnership. Further attention within the community should be given to establishing a functional framework where sustainable funding and risk sharing between private and public organisations allow for our model to be replicated.
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46
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Roopnarinesingh RC, Donlon NE, Reynolds JV. Alkaptonuria: clinical manifestations and an updated approach to treatment of a rare disease. BMJ Case Rep 2021; 14:e244240. [PMID: 34876442 PMCID: PMC8655580 DOI: 10.1136/bcr-2021-244240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2021] [Indexed: 11/04/2022] Open
Abstract
Alkaptonuria (AKU) is a rare autosomal recessive disorder with a global incidence of 1 in 250 000 to 1 million people worldwide. It results from a deficiency of the enzyme homogentisic acid (HGA) oxidase which when absent, leads to an accumulation of HGA. Without this enzymatic degradation, HGA deposits in connective tissues resulting in pigmentation (ochronosis), plaque formation and accelerated cartilage destruction. With this, many patients who suffer from AKU develop ochronotic arthropathies, tendon ruptures, fractures, and chronic joint pain. Similarly, patients can develop cardiac valvular dysfunction and interstitial renal disease. Our two cases highlight the array of pathologies seen in AKU and, in light of newly published research, give us a platform from which we can discuss the developments in management of this rare disease.
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Affiliation(s)
| | | | - John V Reynolds
- Department of Upper GI Surgery, St.James Hospital, Dublin, Ireland
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47
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Teke Kisa P, Eroglu Erkmen S, Bahceci H, Arslan Gulten Z, Aydogan A, Karalar Pekuz OK, Yuce Inel T, Ozturk T, Uysal S, Arslan N. Efficacy of Phenylalanine- and Tyrosine-Restricted Diet in Alkaptonuria Patients on Nitisinone Treatment: Case Series and Review of Literature. ANNALS OF NUTRITION AND METABOLISM 2021; 78:48-60. [PMID: 34736252 DOI: 10.1159/000519813] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/21/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Nitisinone used in alkaptonuria (AKU) can result in keratopathy due to strongly increased tyrosine levels. METHODS This study aimed to investigate nutritional status and changes in plasma tyrosine and phenylalanine and urinary homogentisic acid (u-HGA) levels in 8 adult AKU patients (mean age, 56.3 ± 4.7 years) who were on tyrosine/phenylalanine-restricted diet together with 2 mg/day nitisinone. RESULTS The treatment period was 23.4 ± 6.9 months. Daily dietary protein intake was restricted to 0.8-1.0 g/kg/day. Daily tyrosine intake was restricted to 260-450 mg/day for females and 330-550 mg/day for males. Tyrosine/phenylalanine-free amino acid supplements accounted for an average of 56.1% of daily protein intake. The following assessments were performed: anthropometric and plasma tyrosine level measurements every 2 months; ophthalmological examination every 6 months, and nutritional laboratory analyses and measurements of plasma amino acids and u-HGA once in a year. It was targeted to keep the plasma tyrosine level <500 μmol/L. The plasma tyrosine level was <100 μmol/L before the treatment in all patients and around a mean of 582.5 ± 194.8 μmol/L during the treatment. The diet was rearranged if a plasma tyrosine level of >700 μmol/L was detected. The u-HGA level before and after the 1st year of treatment was 1,429.3 ± 1,073.4 mmol/mol creatinine and 33.6 ± 9.5 mmol/mol creatinine, respectively. None of the patients developed keratopathy or experienced weight loss and protein or micronutrient deficiency. CONCLUSION AKU patients should receive tyrosine/phenylalanine-restricted diet for reducing plasma tyrosine level to the safe range. Tyrosine/phenylalanine-free amino acid supplements can be safely used to enhance dietary compliance. Keratopathy and nutrient deficiency should be frequently monitored.
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Affiliation(s)
- Pelin Teke Kisa
- Department of Pediatric Metabolism and Nutrition, Dokuz Eylul University, Izmir, Turkey, .,Department of Pediatric Metabolism and Nutrition, Behçet Uz Children Research and Training Hospital Izmir, Izmir, Turkey,
| | - Semra Eroglu Erkmen
- Department of Nutrition and Dietetics, Dokuz Eylul University, Izmir, Turkey
| | - Hilal Bahceci
- Department of Nutrition and Dietetics, Dokuz Eylul University, Izmir, Turkey
| | - Zumrut Arslan Gulten
- Department of Pediatric Metabolism and Nutrition, Dokuz Eylul University, Izmir, Turkey
| | - Ayca Aydogan
- Department of Pediatric Metabolism and Nutrition, Dokuz Eylul University, Izmir, Turkey
| | | | - Tuba Yuce Inel
- Department of Rheumatology, Dokuz Eylul University, Izmir, Turkey
| | - Taylan Ozturk
- Department of Ophthalmology, Dokuz Eylul University, Izmir, Turkey
| | - Sezer Uysal
- Department of Biochemistry, Dokuz Eylul University, Izmir, Turkey
| | - Nur Arslan
- Department of Pediatric Metabolism and Nutrition, Dokuz Eylul University, Izmir, Turkey.,Izmir Biomedicine and Genome Center, Izmir, Turkey
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Shepherd RF, Kerns JG, Ranganath LR, Gallagher JA, Taylor AM. "Lessons from Rare Forms of Osteoarthritis". Calcif Tissue Int 2021; 109:291-302. [PMID: 34417863 PMCID: PMC8403118 DOI: 10.1007/s00223-021-00896-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 07/27/2021] [Indexed: 12/12/2022]
Abstract
Osteoarthritis (OA) is one of the most prevalent conditions in the world, particularly in the developed world with a significant increase in cases and their predicted impact as we move through the twenty-first century and this will be exacerbated by the covid pandemic. The degeneration of cartilage and bone as part of this condition is becoming better understood but there are still significant challenges in painting a complete picture to recognise all aspects of the condition and what treatment(s) are most appropriate in individual causes. OA encompasses many different types and this causes some of the challenges in fully understanding the condition. There have been examples through history where much has been learnt about common disease(s) from the study of rare or extreme phenotypes, particularly where Mendelian disorders are involved. The often early onset of symptoms combined with the rapid and aggressive pathogenesis of these diseases and their predictable outcomes give an often-under-explored resource. It is these "rarer forms of disease" that William Harvey referred to that offer novel insights into more common conditions through their more extreme presentations. In the case of OA, GWAS analyses demonstrate the multiple genes that are implicated in OA in the general population. In some of these rarer forms, single defective genes are responsible. The extreme phenotypes seen in conditions such as Camptodactyly Arthropathy-Coxa Vara-pericarditis Syndrome, Chondrodysplasias and Alkaptonuria all present potential opportunities for greater understanding of disease pathogenesis, novel therapeutic interventions and diagnostic imaging. This review examines some of the rarer presenting forms of OA and linked conditions, some of the novel discoveries made whilst studying them, and findings on imaging and treatment strategies.
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Affiliation(s)
- Rebecca F Shepherd
- Lancaster Medical School, Faculty of Health & Medicine, Lancaster University, Lancaster, UK
| | - Jemma G Kerns
- Lancaster Medical School, Faculty of Health & Medicine, Lancaster University, Lancaster, UK
| | - Lakshminarayan R Ranganath
- Departments of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool University Hospital, Liverpool, L7 8XP, UK
| | - James A Gallagher
- Department of Musculoskeletal Biology, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, L7 8T, UK
| | - Adam M Taylor
- Lancaster Medical School, Faculty of Health & Medicine, Lancaster University, Lancaster, UK.
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Wolffenbuttel BHR, Heiner-Fokkema MR, van Spronsen FJ. Preventive use of nitisinone in alkaptonuria. Orphanet J Rare Dis 2021; 16:343. [PMID: 34344451 PMCID: PMC8336241 DOI: 10.1186/s13023-021-01977-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/25/2021] [Indexed: 11/17/2022] Open
Abstract
Alkaptonuria (AKU, OMIM 203500) is a rare congenital disorder caused by a deficiency of the enzyme homogentisate-1,2,-dioxygenase. The long-term consequences of AKU are joint problems, cardiac valve abnormalities and renal problems. Landmark intervention studies with nitisinone 10 mg daily, suppressing an upstream enzyme activity, demonstrated its beneficial effects in AKU patients with established complications, which usually start to develop in the fourth decade. Lower dose of nitisinone in the range of 0.2–2 mg daily will already reduce urinary homogentisic acid (uHGA) excretion by > 90%, which may prevent AKU-related complications earlier in the course of the disease while limiting the possibility of side-effects related to the increase of plasma tyrosine levels caused by nitisinone. Future preventive studies should establish the lowest possible dose for an individual patient, the best age to start treatment and also collect evidence to which level uHGA excretion should be reduced to prevent complications.
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Affiliation(s)
- Bruce H R Wolffenbuttel
- Department of Internal Medicine, Division of Endocrinology, University of Groningen, University Medical Center Groningen, P.O. Box 30001, 9700 RB, Groningen, The Netherlands.
| | - M Rebecca Heiner-Fokkema
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Francjan J van Spronsen
- Beatrix Children's Hospital, Division of Metabolic Disorders, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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50
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Spiekerkoetter U, Couce ML, Das AM, de Laet C, Dionisi-Vici C, Lund AM, Schiff M, Spada M, Sparve E, Szamosi J, Vara R, Rudebeck M. Long-term safety and outcomes in hereditary tyrosinaemia type 1 with nitisinone treatment: a 15-year non-interventional, multicentre study. Lancet Diabetes Endocrinol 2021; 9:427-435. [PMID: 34023005 DOI: 10.1016/s2213-8587(21)00092-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/24/2021] [Accepted: 03/30/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Since the EU approval of nitisinone in 2005, prognosis for patients with hereditary tyrosinaemia type 1 has changed dramatically, with patients living with the disease now reaching adulthood for the first time in history. This study aimed to assess the long-term safety and outcomes of nitisinone treatment in patients with hereditary tyrosinaemia type 1. METHODS We did a non-interventional, non-comparative, multicentre study in 77 sites across 17 countries in Europe and collected retrospective and prospective longitudinal data in patients with hereditary tyrosinaemia type 1 who were treated with oral nitisinone during the study period (Feb 21, 2005, to Sept 30, 2019). There were no specific exclusion criteria. Patients were followed-up with an investigator at least annually for as long as they were treated, or until the end of the study. The primary endpoints, occurrence of adverse events related to hepatic, renal, ophthalmic, haematological, or cognitive or developmental function, were assessed in the complete set (all patients already receiving treatment at the index date [Feb 21, 2005] or starting treatment thereafter) and the index set (the subset of patients who had their first dose on the index date or later only). FINDINGS 315 patients were enrolled during the study period (complete set). Additionally, data from 24 patients who had liver transplantation or died during the post-marketing surveillance programme were retrieved (extended analysis set; 339 patients). Median treatment duration was 11·2 years (range 0·7-28·4); cumulative nitisinone exposure was 3172·7 patient-years. Patients who were diagnosed by neonatal screening started nitisinone treatment at median age 0·8 months versus 8·5 months in those who presented clinically. Incidences of hepatic, renal, ophthalmic, haematological, or cognitive or developmental adverse events were low. Occurrence of liver transplantation or death was more frequent the later that treatment was initiated (none of 70 patients who started treatment at age <28 days vs 35 [13%] of 268 patients who started treatment at age ≥28 days). 279 (89%) of 315 patients were assessed as having either very good or good nitisinone treatment compliance. Treatment and diet compliance declined as patients aged. Suboptimal plasma phenylalanine and tyrosine levels were observed. The majority of patients were reported to have good overall clinical condition throughout treatment; 176 (87%) of 203 during the entire study, 98% following 1 year of treatment. INTERPRETATION Long-term nitisinone treatment was well tolerated and no new safety signals were revealed. Life-limiting hepatic disease appears to have been prevented by early treatment start. Neonatal screening was the most effective way of ensuring early treatment. Standardised monitoring of blood tyrosine, phenylalanine, and nitisinone levels has potential to guide individualised therapy. FUNDING Swedish Orphan Biovitrum (Sobi).
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Affiliation(s)
- Ute Spiekerkoetter
- Department of Paediatrics and Adolescent Medicine, University Medical Centre, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Maria L Couce
- Hospital Clínico Universitario de Santiago de Compostela, Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), MetabERN, Santiago de Compostela, Spain
| | - Anibh M Das
- Department of Paediatrics, Hannover Medical School, Hannover, Germany
| | - Corinne de Laet
- Nutrition and Metabolism Unit, Department of Paediatrics, Hôpital Universitaire des Enfants Reine Fabiola, Brussels, Belgium
| | - Carlo Dionisi-Vici
- Division of Metabolism, Bambino Gesù Children's Hospital Instituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Allan M Lund
- Centre for Inherited Metabolic Diseases, Departments of Paediatrics and Clinical Genetics, Copenhagen University Hospital, Copenhagen, Denmark
| | - Manuel Schiff
- Necker Hospital, AP-HP, Reference Centre for Inborn Error of Metabolism (Filière G2M), Paediatrics Department, University of Paris, Paris, France; Inserm UMR_S1163, Institut Imagine, Paris, France
| | - Marco Spada
- Department of Paediatrics, Regina Margherita Children Hospital, University of Torino, Torino, Italy
| | - Erik Sparve
- Swedish Orphan Biovitrum (Sobi), Stockholm, Sweden
| | | | - Roshni Vara
- Department of Paediatric Inherited Metabolic Disease, Evelina London Children's Hospital, London, UK
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