1
|
Yilmaz O, Pinto A, Daly A, Ashmore C, Evans S, Yabanci Ayhan N, MacDonald A. Transitioning of protein substitutes in patients with phenylketonuria: evaluation of current practice. Orphanet J Rare Dis 2022; 17:395. [PMID: 36303225 PMCID: PMC9615388 DOI: 10.1186/s13023-022-02555-8] [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: 07/29/2022] [Accepted: 10/11/2022] [Indexed: 11/27/2022] Open
Abstract
Background In children with phenylketonuria (PKU), transitioning protein substitutes at the appropriate developmental age is essential to help with their long-term acceptance and ease of administration. We assessed the parental experiences in transitioning from a second stage to third stage liquid or powdered protein substitute in patients with PKU. Results Sixteen interviews (23 open-ended questions) were carried out with parents/caregivers of children with PKU (8 females, 50%) with a median age of 8 years (range 5–11 years), continuously treated with diet, and on a third stage protein substitute. Parents/caregivers identified common facilitators and barriers during the third stage protein substitute transition process. The main facilitators were: child and parent motivation, parent knowledge of the transition process, a role model with PKU, low volume and easy preparation of the third stage protein substitute (liquid/powder), anticipation of increasing child independence, lower parent workload, attractive packaging, better taste and smell, school and teacher support, dietetic plans and guidance, PKU social events, child educational materials and written resources. The main barriers were child aversion to new protein substitutes, poor child behaviour, child aged > 5 years, parental fear of change, the necessity for parental time and persistence, loss of parental control, high product volume, different taste, smell, and texture of new protein substitutes, and peer bullying. Conclusion A stepwise, supportive approach is necessary when transitioning from second to third stage protein substitutes in PKU. Future studies are needed to develop guidance to assist parents/caregivers, health professionals, and teachers during the transition process.
Collapse
Affiliation(s)
- Ozlem Yilmaz
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, B4 6NH, UK. .,Department of Nutrition and Dietetics, Faculty of Health Sciences, Ankara Yildirim Beyazit University, Ankara, 06760, Turkey. .,Department of Nutrition and Dietetics, Faculty of Health Sciences, Ankara University, Ankara, 06290, Turkey.
| | - Alex Pinto
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, B4 6NH, UK
| | - Anne Daly
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, B4 6NH, UK
| | - Catherine Ashmore
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, B4 6NH, UK
| | - Sharon Evans
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, B4 6NH, UK
| | - Nurcan Yabanci Ayhan
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Ankara University, Ankara, 06290, Turkey
| | - Anita MacDonald
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, B4 6NH, UK.
| |
Collapse
|
2
|
Firman SJ, Ramachandran R, Whelan K, Witard OC, O’Keeffe M. Protein status in phenylketonuria: A scoping review. Clin Nutr 2022; 41:894-922. [DOI: 10.1016/j.clnu.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/01/2022] [Accepted: 02/14/2022] [Indexed: 11/03/2022]
|
3
|
Burlina A, Leuzzi V, Spada M, Carbone MT, Paci S, Tummolo A. The management of phenylketonuria in adult patients in Italy: a survey of six specialist metabolic centers. Curr Med Res Opin 2021; 37:411-421. [PMID: 33222540 DOI: 10.1080/03007995.2020.1847717] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Phenylketonuria (PKU) is a rare autosomal recessive disorder caused by a deficiency of phenylalanine hydroxylase (PAH). Its prevalence is estimated to be 1:10,000 in Europe. PKU is the commonest congenital inborn error of metabolism. The aim of our study was to investigate the characteristics of clinical practice in relation to PKU in Italy, in order to raise awareness about the current management and therapeutic approaches adopted. METHODS Six Italian experts conducted a systematic literature review as well as an internal survey to investigate the relevant clinical aspects. Collectively, the expert panel managed a total of 678 PKU patients treated in the early stages of the condition over a 16-year period across six centers. RESULTS The management of PKU varied markedly between centers, with differences in the composition of the multidisciplinary team, dietary treatments, compliance and adherence to management, tetrahydrobiopterin use, and patient follow-up. Patients were mostly managed by a pediatric reference center from the initial PKU diagnosis during newborn screening until adulthood, without transition to a specialized adult clinician. Fogginess, concentration reduction, low attention, anxiety, irritability, memory deficit, headache, and unstable mood were common features in patients with uncontrolled blood phenylalanine levels (generally above 600 µmol/L). CONCLUSION A homogeneous and shared approach to the management of PKU patients is important. Our survey demonstrates the current management of PKU in Italy, with the aim of promoting the implementation of therapeutic strategies and follow-up, increased patient compliance and adherence, and the achievement of the phenylalanine level targets recommended by European Union guidelines. Emerging therapies are likely to become a standard treatment for patients unable to comply with diet therapy and maintain their phenylalanine levels below the threshold values. UNLABELLED Supplemental data for this article is available online at https://doi.org/10.1080/03007995.2020.1847717.
Collapse
Affiliation(s)
- Alberto Burlina
- Inherited Metabolic Diseases Division, Regional Center for Expanded Neonatal Screening, Women and Children's Health Department, University Hospital of Padua, Padua, Italy
| | - Vincenzo Leuzzi
- Department of Human Neuroscience, Unit of Child Neurology and Psychiatry, University La Sapienza, Rome, Italy
| | - Marco Spada
- Department of Pediatrics, Regina Margherita Children's Hospital, University of Torino, Torino, Italy
| | - Maria Teresa Carbone
- Pediatric Division, Metabolic and Rare Diseases, Santobono Pausilipon Hospital, Naples, Italy
| | - Sabrina Paci
- Pediatric Department, ASST Santi Paolo e Carlo, San Paolo Hospital, University of Milan, Milan, Italy
| | - Albina Tummolo
- Metabolic Diseases Department, Clinical Genetics and Diabetology, Giovanni XXIII Children's Hospital, Bari, Italy
| |
Collapse
|
4
|
Douglas TD, Nucci AM, Berry AM, Henes ST, Singh RH. Large neutral amino acid status in association with P:T ratio and diet in adult and pediatric patients with phenylketonuria. JIMD Rep 2019; 50:50-59. [PMID: 31741827 PMCID: PMC6850973 DOI: 10.1002/jmd2.12076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 08/09/2019] [Accepted: 08/13/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Intake of large neutral amino acids (LNAA) may inhibit phenylalanine (PHE) transport across the blood brain barrier and assist with blood PHE control in patients with phenylketonuria (PKU). We evaluated the interrelationship between LNAA in plasma and diet on Phe:Tyr (P:T) ratio in patients with PKU and the influence of dietary factors on plasma LNAA markers. METHODS Plasma amino acid values and 3-day food record analysis from two studies (34 male/30 female; age 4.6-47 years) were examined. For pediatrics (<18 years) and adults (≥18 years) the relationship between P:T ratio, plasma LNAA, and dietary intake patterns were investigated. RESULTS Dietary factors influencing P:T ratio included intake of total protein (g/kg), medical food (MF) protein (g/kg, % below Rx), and LNAA (g) in the full cohort (P < .05). Associations were found between plasma valine and other dietary and plasma LNAA in pediatrics (P < .05) and plasma LNAA with dietary LNAA intake in adults (P = .019). Plasma P:T ratio was inversely associated with plasma LNAA concentrations in both age groups (P < .05). Aside from histidine in pediatrics (P = .024), plasma LNAA did not differ by having plasma PHE levels within or above the therapeutic range (120-360 μmol/L). Plasma LNAA in both age groups was similar to reported healthy control values. CONCLUSION P:T ratio is significantly tied to dietary LNAA, adherence to MF Rx, and plasma LNAA concentrations. Additionally, P:T ratio and valine may be effective clinical proxies for determining LNAA metabolic balance and LNAA quality of the diet in patients with PKU.
Collapse
Affiliation(s)
| | - Anita M. Nucci
- Department of NutritionGeorgia State UniversityAtlantaGeorgia
| | - Ann M. Berry
- Department of NutritionGeorgia State UniversityAtlantaGeorgia
| | - Sarah T. Henes
- Department of NutritionGeorgia State UniversityAtlantaGeorgia
| | - Rani H. Singh
- Department of Human GeneticsEmory UniversityAtlantaGeorgia
| |
Collapse
|
5
|
van Wegberg AMJ, MacDonald A, Ahring K, Bélanger-Quintana A, Blau N, Bosch AM, Burlina A, Campistol J, Feillet F, Giżewska M, Huijbregts SC, Kearney S, Leuzzi V, Maillot F, Muntau AC, van Rijn M, Trefz F, Walter JH, van Spronsen FJ. The complete European guidelines on phenylketonuria: diagnosis and treatment. Orphanet J Rare Dis 2017; 12:162. [PMID: 29025426 PMCID: PMC5639803 DOI: 10.1186/s13023-017-0685-2] [Citation(s) in RCA: 381] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 07/11/2017] [Indexed: 12/22/2022] Open
Abstract
Phenylketonuria (PKU) is an autosomal recessive inborn error of phenylalanine metabolism caused by deficiency in the enzyme phenylalanine hydroxylase that converts phenylalanine into tyrosine. If left untreated, PKU results in increased phenylalanine concentrations in blood and brain, which cause severe intellectual disability, epilepsy and behavioural problems. PKU management differs widely across Europe and therefore these guidelines have been developed aiming to optimize and standardize PKU care. Professionals from 10 different European countries developed the guidelines according to the AGREE (Appraisal of Guidelines for Research and Evaluation) method. Literature search, critical appraisal and evidence grading were conducted according to the SIGN (Scottish Intercollegiate Guidelines Network) method. The Delphi-method was used when there was no or little evidence available. External consultants reviewed the guidelines. Using these methods 70 statements were formulated based on the highest quality evidence available. The level of evidence of most recommendations is C or D. Although study designs and patient numbers are sub-optimal, many statements are convincing, important and relevant. In addition, knowledge gaps are identified which require further research in order to direct better care for the future.
Collapse
Affiliation(s)
- A. M. J. van Wegberg
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, PO BOX 30.001, 9700 RB Groningen, The Netherlands
| | - A. MacDonald
- Dietetic Department, Birmingham Children’s Hospital, Birmingham, UK
| | - K. Ahring
- Department of PKU, Kennedy Centre, Glostrup, Denmark
| | - A. Bélanger-Quintana
- Metabolic Diseases Unit, Department of Paediatrics, Hospital Ramon y Cajal Madrid, Madrid, Spain
| | - N. Blau
- University Children’s Hospital, Dietmar-Hoppe Metabolic Centre, Heidelberg, Germany
- University Children’s Hospital Zürich, Zürich, Switzerland
| | - A. M. Bosch
- Department of Paediatrics, Division of Metabolic Disorders, Academic Medical Centre, University Hospital of Amsterdam, Amsterdam, The Netherlands
| | - A. Burlina
- Division of Inherited Metabolic Diseases, Department of Paediatrics, University Hospital of Padova, Padova, Italy
| | - J. Campistol
- Neuropaediatrics Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - F. Feillet
- Department of Paediatrics, Hôpital d’Enfants Brabois, CHU Nancy, Vandoeuvre les Nancy, France
| | - M. Giżewska
- Department of Paediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology of the Developmental Age, Pomeranian Medical University, Szczecin, Poland
| | - S. C. Huijbregts
- Department of Clinical Child and Adolescent Studies-Neurodevelopmental Disorders, Faculty of Social Sciences, Leiden University, Leiden, The Netherlands
| | - S. Kearney
- Clinical Psychology Department, Birmingham Children’s Hospital, Birmingham, UK
| | - V. Leuzzi
- Department of Paediatrics, Child Neurology and Psychiatry, Sapienza University of Rome, Via dei Sabelli 108, 00185 Rome, Italy
| | - F. Maillot
- CHRU de Tours, Université François Rabelais, INSERM U1069, Tours, France
| | - A. C. Muntau
- University Children’s Hospital, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - M. van Rijn
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, PO BOX 30.001, 9700 RB Groningen, The Netherlands
| | - F. Trefz
- Department of Paediatrics, University of Heidelberg, Heidelberg, Germany
| | - J. H. Walter
- Medicine, Manchester Academic Health Sciences Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - F. J. van Spronsen
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, PO BOX 30.001, 9700 RB Groningen, The Netherlands
| |
Collapse
|
6
|
Pena MJ, de Almeida MF, van Dam E, Ahring K, Bélanger-Quintana A, Dokoupil K, Gokmen-Ozel H, Lammardo AM, MacDonald A, Robert M, Rocha JC. Protein substitutes for phenylketonuria in Europe: access and nutritional composition. Eur J Clin Nutr 2016; 70:785-9. [PMID: 27117930 DOI: 10.1038/ejcn.2016.54] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 02/01/2016] [Accepted: 02/26/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Protein substitutes (PS) are an essential component in the dietary management of phenylketonuria (PKU). PS are available as phenylalanine-free amino-acid mixtures (AAM), glycomacropeptide-based PS (GMP) and large neutral amino acids (LNAA). There is a lack of information regarding their availability in different countries and comparison of their nutritional composition is limited. The objectives of this study were to identify the number of PS available in different European countries and Turkey and to compare their nutritional composition. SUBJECTS/METHODS Members of the European Nutritionist Expert Panel on PKU (ENEP) (Portugal, Spain, Belgium, Italy, Germany, Netherlands, United Kingdom, Denmark and Turkey) provided data on PS available in each country. The nutritional composition of PS available in Portugal was analyzed. RESULTS The number of PS available in each country varied from 30 (Turkey) to 105 (Germany), with a median of 64. GMP was available only in Portugal, whereas LNAA was an option in Portugal, Italy, Turkey and Denmark. Some PS were designed for weaning. Many PS did not contain added fat and fiber. GMP contained the highest carbohydrate (CHO) and energy content as well as higher LNAA content compared with AAM. Only one AAM contained added fructo-oligosaccharides and galacto-oligosaccharides. AAM designed for the first year of life had the highest CHO, fat and LNAA contribution. Liquid AAM had lower CHO and fat contents compared with powdered AAM, but contained higher LNAA. CONCLUSIONS There was widely dissimilar numbers of PS available in different countries. Nutritional composition of different PS was variable and should be considered before prescription.
Collapse
Affiliation(s)
- M J Pena
- Centro de Genética Médica, Centro Hospitalar do Porto (CHP), Porto, Portugal
| | - M F de Almeida
- Centro de Genética Médica, Centro Hospitalar do Porto (CHP), Porto, Portugal.,Unit for Multidisciplinary Research in Biomedicine (UMIB), Instituto de Ciências Biomédicas Abel Salazar (ICBAS), University of Porto, Porto, Portugal
| | - E van Dam
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, The Netherlands
| | - K Ahring
- Department of PKU, Kennedy Centre, Copenhagen University Hospital, Glostrup, Denmark
| | - A Bélanger-Quintana
- Unidad Enfermedades Metabolicas Servicio de Pediatria Hospital Ramon y Cajal, Madrid, Spain
| | - K Dokoupil
- Department of Metabolism and Nutrition, Dr von Hauner Children's Hospital, University of Munich, Munich, Germany
| | - H Gokmen-Ozel
- Department of Nutrition and Dietetics, Hacettepe University, Ankara, Turkey
| | - A M Lammardo
- Department of Pediatrics, San Paolo Hospital University of Milan, Milan, Italy
| | | | - M Robert
- Nutrition and Metabolism Unit, Hôpital Universitaire des Enfants Reine Fabiola, Brussels, Belgium
| | - J C Rocha
- Centro de Genética Médica, Centro Hospitalar do Porto (CHP), Porto, Portugal.,Faculdade de Ciências da Saúde, Universidade Fernando Pessoa, Porto, Portugal.,Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
| |
Collapse
|
7
|
Daly A, Evans S, Chahal S, Surplice I, Vijay S, Santra S, MacDonald A. The challenges of vitamin and mineral supplementation in children with inherited metabolic disorders: a prospective trial. J Hum Nutr Diet 2016; 29:434-40. [PMID: 26781762 DOI: 10.1111/jhn.12354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND In order to achieve metabolic stability, dietary treatment of inborn errors of metabolism may require restriction of protein, fat or carbohydrate. Manipulation of dietary intake potentially reduces micronutrient status, and provision of a comprehensive vitamin and mineral supplement becomes an essential adjunct to dietary treatment. AIM To review the efficacy of a new complete vitamin and mineral supplement [Fruitivits, Vitaflo Ltd] in 14 subjects in an open prospective 26-week study. METHOD All subjects had dietary restrictions: low protein diets (57%, n = 8), regular daytime cornstarch and overnight glucose polymer tube feeds (29%, n = 4), low fat diet (7%, n = 1) and modified Atkins diet (7%, n = 1). Plasma nutritional biochemistry, anthropometry and food frequency questionnaires were collected at week 0, 12 and 26 weeks respectively. RESULTS Five nutritional parameters showed a significant improvement from baseline (week 0) to study end (week 26): folate (P = 0.01), vitamin E (P = 0.04), plasma selenium (P = 0.002), whole blood selenium (P = 0.04) and total vitamin D (P = 0.008). All the other nutritional markers did not significantly change. Even with regular monitoring, 37% of the product remained unused. CONCLUSIONS Despite improvements in some nutritional markers, overall use of the vitamin and mineral supplement was less than prescribed. New methods are needed to guarantee delivery of micronutrients in children at risk of deficiencies as a result of an essential manipulation of diet in inborn disorders of metabolism.
Collapse
Affiliation(s)
- A Daly
- Department of Dietetics, Birmingham Children's Hospital, Birmingham, UK
| | - S Evans
- Department of Dietetics, Birmingham Children's Hospital, Birmingham, UK
| | - S Chahal
- Department of Dietetics, Birmingham Children's Hospital, Birmingham, UK
| | - I Surplice
- Department of Biochemistry, Birmingham Children's Hospital, Birmingham, UK
| | - S Vijay
- Department of Inherited Metabolic Disorders, Birmingham Children's Hospital, Birmingham, UK
| | - S Santra
- Department of Inherited Metabolic Disorders, Birmingham Children's Hospital, Birmingham, UK
| | - A MacDonald
- Department of Dietetics, Birmingham Children's Hospital, Birmingham, UK
| |
Collapse
|
8
|
Cochrane B, Schwahn B, Galloway P, Robinson P, Gerasimidis K. A questionnaire survey on the usage of low protein staple foods by people with phenylketonuria in Scotland. J Hum Nutr Diet 2014; 27:533-41. [PMID: 24387232 DOI: 10.1111/jhn.12199] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is scarce evidence available with respect to an evaluation of the role of low protein staple foods (LPSF) in the management of phenylketonuria (PKU). The present study explored beliefs, acceptability and issues around the use of LPSF by people with PKU or their carers. METHODS A semi-anonymous questionnaire was posted to 178 people with PKU in Scotland (104 children, aged 2-17 years, and 74 adults). Questions explored were: the type and amount of LPSF ordered; perceptions on use and usefulness of LPSF; acceptability of the LPSF sensory properties (i.e. taste, smell, texture, appearance); support for the supply and use of LPSF; and comments from primary healthcare professionals regarding dispensing and prescription. RESULTS Eighty-two individuals responded (46% response rate): 97% perceived that LPSF were useful for PKU management; more than 85% reported that LPSF were important for phenylalanine control, satisfying appetite, and diet variety. The most common LPSF ordered were pasta/rice/cous cous, flour, biscuits and bread. Fifty percent of respondents ordered <51% of the recommended unit allowance of LPSF. The sensory properties of LPSF were well perceived. Forty-nine percent (n = 39) had received a comment from primary healthcare staff regarding the prescription or dispensing of LPSF; 59% (n = 23) received negative comments, the majority of which came within general practitioner surgeries. CONCLUSIONS There is a positive attitude and perception on the use and usefulness of LPSF in the management of PKU. Issues with respect to the supply and provision of LPSF within primary health care may indicate poor communication between specialists and primary healthcare professionals or a lack of scientific evidence demonstrating their clinical effectiveness.
Collapse
Affiliation(s)
- B Cochrane
- Human Nutrition, School of Medicine, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Royal Hospital for Sick Children, Glasgow, UK
| | | | | | | | | |
Collapse
|
9
|
Mazzola PN, Karikas GA, Schulpis KH, Dutra-Filho CS. Antioxidant treatment strategies for hyperphenylalaninemia. Metab Brain Dis 2013; 28:541-50. [PMID: 23657560 DOI: 10.1007/s11011-013-9414-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2013] [Accepted: 05/01/2013] [Indexed: 12/12/2022]
Abstract
Hyperphenylalaninemia (HPA) leads to increased oxidative stress in patients with phenylketonuria (PKU) and in animal models of PKU. Early diagnosis and immediate adherence to a phenylalanine-restricted diet prevents HPA and, consequently, severe brain damage. However, treated adolescent and adult PKU patients have difficulties complying with the diet, leading to an oscillation of phenylalanine levels and associated oxidative stress. The brain is especially susceptible to reactive species, and oxidative stress might add to the impaired cognitive function found in these patients. The restricted PKU diet has a very limited nutrient content from natural foods and almost no animal protein, which reduces the intake of important compounds. These specific compounds can act as scavengers of reactive species and can be co-factors of antioxidant enzymes. Supplementation with nutrients, vitamins, and tetrahydropterin has given quite promising results in patients and animal models. Antioxidant supplementation has been studied in HPA, however there is no consensus about its always beneficial effects. In this way, regular exercise could be a beneficial addition on antioxidant status in PKU patients. A deeper understanding of PKU molecular biochemistry, and genetics, as well as the need for improved targeted treatment options, could lead to the development of new therapeutic strategies.
Collapse
Affiliation(s)
- Priscila Nicolao Mazzola
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica. Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600 - Anexo, CEP 90035-003, Porto Alegre, RS, Brazil,
| | | | | | | |
Collapse
|
10
|
Knerr I, Blessing H, Seyferth S, Watling RJ, Chaudhri MA. Evaluation of plasma trace element and mineral status in children and adolescents with phenylketonuria using data from inductively-coupled-plasma atomic emission and mass spectrometric analysis. ANNALS OF NUTRITION AND METABOLISM 2013; 63:168-73. [PMID: 24021752 DOI: 10.1159/000354869] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 07/31/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Phenylketonuria (PKU) is caused by a severe phenylalanine hydroxylase deficiency; the mainstay of treatment is a low-phenylalanine diet. A diet which is so restrictive is associated with a risk of nutritional deficiencies. We investigated plasma concentrations for 46 elements, including minerals and trace elements. METHODS We enrolled 20 children and adolescents with PKU and 20 matched controls. Multi-elementary quantification was carried out by solution-based inductively coupled plasma atomic emission spectroscopy (ICP-AES) and ICP mass spectrometry (ICP-MS). RESULTS With the exception of manganese and aluminium, no significant differences were found for element levels between PKU patients and controls. As a trend, manganese levels were lower in PKU patients than in control subjects (p < 0.05) but were within the reference range. There was a positive linear relationship between manganese and tyrosine levels in subjects with PKU (r(2) = 0.2295, p < 0.05). If detectable, potentially toxic elements were only identified in ultra-trace quantities in plasma samples of either group; aluminium levels were found to be slightly higher in PKU subjects than in controls (p < 0.01). CONCLUSION The combination of ICP-AES and ICP-MS data is a useful diagnostic tool for element quantification at a high analytical rate and for monitoring bio-element status, e.g. in patients on a restrictive diet.
Collapse
Affiliation(s)
- I Knerr
- National Centre for Inherited Metabolic Disorders, Children's University Hospital, Dublin, Ireland
| | | | | | | | | |
Collapse
|
11
|
Robert M, Rocha JC, van Rijn M, Ahring K, Bélanger-Quintana A, MacDonald A, Dokoupil K, Gokmen Ozel H, Lammardo AM, Goyens P, Feillet F. Micronutrient status in phenylketonuria. Mol Genet Metab 2013; 110 Suppl:S6-17. [PMID: 24113686 DOI: 10.1016/j.ymgme.2013.09.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2013] [Revised: 09/15/2013] [Accepted: 09/15/2013] [Indexed: 12/12/2022]
Abstract
Patients with phenylketonuria (PKU) encompass an 'at risk' group for micronutrient imbalances. Optimal nutrient status is challenging particularly when a substantial proportion of nutrient intake is from non-natural sources. In PKU patients following dietary treatment, supplementation with micronutrients is a necessity and vitamins and minerals should either be added to supplement phenylalanine-free l-amino acids or given separately. In this literature review of papers published since 1990, the prevalence of vitamin and mineral deficiency is described, with reference to age of treatment commencement, type of treatment, dietary compliance, and dietary practices. Biological micronutrient inadequacies have been mainly reported for zinc, selenium, iron, vitamin B12 and folate. The aetiology of these results and possible clinical and biological implications are discussed. In PKU there is not a simple relationship between the dietary intake and nutritional status, and there are many independent and interrelated complex factors that should be considered other than quantitative nutritional intake.
Collapse
Affiliation(s)
- M Robert
- Nutrition and Metabolism Unit, Hôpital Universitaire des Enfants Reine Fabiola, Brussels, Belgium
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Rocha JC, van Spronsen FJ, Almeida MF, Ramos E, Guimarães JT, Borges N. Early dietary treated patients with phenylketonuria can achieve normal growth and body composition. Mol Genet Metab 2013; 110 Suppl:S40-3. [PMID: 24183791 DOI: 10.1016/j.ymgme.2013.10.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 10/15/2013] [Indexed: 01/10/2023]
Abstract
BACKGROUND In the past, overtreatment may have resulted in growth impairment in patients with phenylketonuria. OBJECTIVE The paper aims to investigate height and body composition in early treated patients with phenylketonuria who were diagnosed between 1981 and 2008. DESIGN A cross-sectional study of 89 patients with phenylketonuria and 78 controls aged (mean ± SD, in years) 14.4 ± 6.6 and 15.9 ± 7.1, respectively, was undertaken, including anthropometric and body composition evaluation using bioelectrical impedance. Median Phe concentrations in the last year before study enrollment were used as a measure of metabolic control. Natural protein and amino acid mixture intakes were recorded in patients. RESULTS No statistically significant differences were found on height z-scores between patients and controls aged less than 19 years (p=0.301), although all patients with classical phenylketonuria revealed negative height z-scores, resulting in a mean ± SD of -0.65 ± 0.41. Among participants aged 19 years or more, median (p25-p75) of height was significantly higher in controls [168.0 cm (159.2-174.8)] than in patients [160.5 cm (151.9-167.5)] (p=0.017). No significant differences were found between patients and controls regarding fat mass, fat free mass, muscular mass, body cell mass index and phase angle. CONCLUSION Our results suggest that early and continuously treated patients with phenylketonuria born after 1992 can achieve normal growth and body composition, although the negative height z-score in patients with classical phenylketonuria strengthens the continuous need to optimize the quality of their protein intake.
Collapse
Affiliation(s)
- Júlio C Rocha
- Center of Medical Genetics Jacinto de Magalhães, CHP, EPE, Porto, Portugal.
| | | | | | | | | | | |
Collapse
|
13
|
Rocha JC, van Spronsen FJ, Almeida MF, Soares G, Quelhas D, Ramos E, Guimarães JT, Borges N. Dietary treatment in phenylketonuria does not lead to increased risk of obesity or metabolic syndrome. Mol Genet Metab 2012; 107:659-63. [PMID: 23137570 DOI: 10.1016/j.ymgme.2012.10.006] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Accepted: 10/09/2012] [Indexed: 01/10/2023]
Abstract
BACKGROUND Little is known about the consequences of the special energy enriched diet used to treat patients with phenylketonuria (PKU) in terms of obesity and metabolic syndrome (MetSyn) development. OBJECTIVE To investigate the prevalence of overweight and obesity, and its consequences in terms of body composition and MetSyn in early treated patients with PKU compared to controls. DESIGN A sample of 89 patients with PKU (3-30 y; 14.4±6.6 y) and 79 controls (3-47 y; 16.3±7.9 y) were studied. In the fasted state, anthropometric, body composition, blood pressure and analytical parameters [amino acids, glucose, insulin, total and HDL-cholesterol (HDL-c), triglycerides (TG), high sensitivity c-reactive protein and uric acid] were performed. Data on dietary intake was collected. BMI was classified using WHO criteria, while the definition from International Diabetes Federation (IDF) was used for MetSyn. RESULTS Prevalence of overweight and obesity (32.6% vs. 24.1%; p=0.293), body fat percentage (22% vs. 23.1%, p=0.581) and central obesity (36.9% vs. 36.4%, p=0.999) were comparable to controls. Patients revealed a higher TG/HDL-c (p<0.001). The prevalence of MetSyn was 1.5% and 6.1% in patients and controls, respectively. Patients and not controls with central obesity revealed a further significant increase in TG/HDL-c compared with those without central obesity (p=0.023). CONCLUSION Patients and controls were similar in terms of overweight and obesity, body composition and MetSyn. However, the dyslipidemia in patients with PKU in relation to overweight and obesity may help us trying to understand the course and the etiology of MetSyn not only in PKU but also in the general population.
Collapse
Affiliation(s)
- Júlio C Rocha
- Center of Medical Genetics Jacinto de Magalhães-INSA, IP, Porto, Portugal.
| | | | | | | | | | | | | | | |
Collapse
|
14
|
Belanger-Quintana A, Dokoupil K, Gokmen-Ozel H, Lammardo AM, MacDonald A, Motzfeldt K, Nowacka M, Robert M, van Rijn M, Ahring K. Diet in phenylketonuria: a snapshot of special dietary costs and reimbursement systems in 10 international centers. Mol Genet Metab 2012; 105:390-4. [PMID: 22217429 DOI: 10.1016/j.ymgme.2011.12.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 12/06/2011] [Accepted: 12/06/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND AND AIMS To gather exploratory data on the costs and reimbursement of special dietary foods used in the management of phenylketonuria (PKU) from ten international specialist PKU centers. METHODS Experts from each center provided data on retail costs of the three most frequently used phenylalanine-free protein substitutes and low-protein foods at their center; reimbursement of protein substitutes and low-protein foods; and state monetary benefits provided to PKU patients. RESULTS The mean annual cost of protein substitutes across 4 age groups (2 y, 8 y, 15 y and adults) ranged from €4273 to €21,590 per patient. The cost of low-protein products also differed; the mean cost of low-protein bread varied from €0.04 to €1.60 per 100 kcal. All protein substitutes were either fully reimbursed or covered by health insurance. However, reimbursement for low-protein products varied and state benefits differed between centers. CONCLUSIONS The variation in the cost and reimbursement of diet therapy and the level of additional state benefits for PKU patients demonstrates the large difference in expenditure on and access to PKU dietary products. This highlights the inequality between healthcare systems and access to special dietary products for people with PKU, ultimately leading to patients in some countries receiving better care than others.
Collapse
Affiliation(s)
- A Belanger-Quintana
- Unidad de Enfermedades Metabolicas, Servicio de Pediatría, Hospital Ramón y Cajal, Madrid, Spain
| | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Demirkol M, Giżewska M, Giovannini M, Walter J. Follow up of phenylketonuria patients. Mol Genet Metab 2011; 104 Suppl:S31-9. [PMID: 22018725 DOI: 10.1016/j.ymgme.2011.08.005] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Revised: 07/31/2011] [Accepted: 08/07/2011] [Indexed: 11/26/2022]
Abstract
In recent years our understanding of the follow up policies for PKU has increased substantially. In particular, we now understand the importance of maintaining control of blood phenylalanine (phe) concentrations life-long to achieve the best long-term neuropsychological outcomes. The concordance with the follow up strategy remains a key challenge for the future, especially with respect to adolescents and young adults. The recent therapies could ease the burden of the dietary phe restriction for PKU patients and their families. The time may be right for revisiting the guidelines for follow up of PKU in order to address a number of important issues related to PKU management: promotion of breastfeeding to complementary feeding up to 2 years of age for prevention of early growth retardation and later overweight development, treatment advancements for metabolic control, blood phe and tyr variability, routine screening measures for nutritional biomarkers, neurocognitive and psychological assessments, bone pathology, understanding the challenges of compliance and transitioning into adulthood as an individual with PKU and addressing unmet needs in this population.
Collapse
Affiliation(s)
- M Demirkol
- Div Nutrition and Metabolism, Children's Hospital, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey.
| | | | | | | |
Collapse
|
16
|
Hopkins D. Collaborative working: piecing together the paediatric jigsaw. J Hum Nutr Diet 2009; 22:381-2. [PMID: 19743976 DOI: 10.1111/j.1365-277x.2009.00997.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|