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Maiorana A, Lepri FR, Novelli A, Dionisi-Vici C. Hypoglycaemia Metabolic Gene Panel Testing. Front Endocrinol (Lausanne) 2022; 13:826167. [PMID: 35422763 PMCID: PMC9001947 DOI: 10.3389/fendo.2022.826167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/21/2022] [Indexed: 12/31/2022] Open
Abstract
A large number of inborn errors of metabolism present with hypoglycemia. Impairment of glucose homeostasis may arise from different biochemical pathways involving insulin secretion, fatty acid oxidation, ketone bodies formation and degradation, glycogen metabolism, fructose and galactose metabolism, branched chain aminoacids and tyrosine metabolism, mitochondrial function and glycosylation proteins mechanisms. Historically, genetic analysis consisted of highly detailed molecular testing of nominated single genes. However, more recently, the genetic heterogeneity of these conditions imposed to perform extensive molecular testing within a useful timeframe via new generation sequencing technology. Indeed, the establishment of a rapid diagnosis drives specific nutritional and medical therapies. The biochemical and clinical phenotypes are critical to guide the molecular analysis toward those clusters of genes involved in specific pathways, and address data interpretation regarding the finding of possible disease-causing variants at first reported as variants of uncertain significance in known genes or the discovery of new disease genes. Also, the trio's analysis allows genetic counseling for recurrence risk in further pregnancies. Besides, this approach is allowing to expand the phenotypic characterization of a disease when pathogenic variants give raise to unexpected clinical pictures. Multidisciplinary input and collaboration are increasingly key for addressing the analysis and interpreting the significance of the genetic results, allowing rapidly their translation from bench to bedside.
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Affiliation(s)
- Arianna Maiorana
- Division of Metabolism, Department of Pediatrics Subspecialties, Ospedale Pediatrico Bambino Gesù, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
- *Correspondence: Arianna Maiorana,
| | - Francesca Romana Lepri
- Laboratory of Medical Genetics, Translational Cytogenomics Research Unity, Ospedale Pediatrico Bambino Gesù, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
| | - Antonio Novelli
- Laboratory of Medical Genetics, Translational Cytogenomics Research Unity, Ospedale Pediatrico Bambino Gesù, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
| | - Carlo Dionisi-Vici
- Division of Metabolism, Department of Pediatrics Subspecialties, Ospedale Pediatrico Bambino Gesù, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
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Rossi A, Hoogeveen IJ, Lubout CMA, de Boer F, Fokkert‐Wilts MJ, Rodenburg IL, van Dam E, Grünert SC, Martinelli D, Scarpa M, Dekker H, te Boekhorst ST, van Spronsen FJ, Derks TGJ. A generic emergency protocol for patients with inborn errors of metabolism causing fasting intolerance: A retrospective, single-center study and the generation of www.emergencyprotocol.net. J Inherit Metab Dis 2021; 44:1124-1135. [PMID: 33844307 PMCID: PMC8518720 DOI: 10.1002/jimd.12386] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 03/17/2021] [Accepted: 04/09/2021] [Indexed: 01/03/2023]
Abstract
Patients with inborn errors of metabolism causing fasting intolerance can experience acute metabolic decompensations. Long-term data on outcomes using emergency letters are lacking. This is a retrospective, observational, single-center study of the use of emergency letters based on a generic emergency protocol in patients with hepatic glycogen storage diseases (GSD) or fatty acid oxidation disorders (FAOD). Data on hospital admissions, initial laboratory results, and serious adverse events were collected. Subsequently, the website www.emergencyprotocol.net was generated in the context of the CONNECT MetabERN eHealth project following multiple meetings, protocol revisions, and translations. Representing 470 emergency protocol years, 127 hospital admissions were documented in 54/128 (42%) patients who made use of emergency letters generated based on the generic emergency protocol. Hypoglycemia (here defined as glucose concentration < 3.9 mmol/L) was reported in only 15% of hospital admissions and was uncommon in patients with ketotic GSD and patients with FAOD aged >5 years. Convulsions, coma, or death was not documented. By providing basic information, emergency letters for individual patients with hepatic GSD or the main FAOD can be generated at www.emergencyprotocol.net, in nine different languages. Generic emergency protocols are safe and easy for home management by the caregivers and the first hour in-hospital management to prevent metabolic emergencies in patients with hepatic GSD and medium-chain Acyl CoA dehydrogenase deficiency. The website www.emergencyprotocol.net is designed to support families and healthcare providers to generate personalized emergency letters for patients with hepatic GSD and the main FAOD.
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Affiliation(s)
- Alessandro Rossi
- Section of Metabolic DiseasesBeatrix Children's Hospital, University Medical Centre Groningen, University of GroningenGroningenThe Netherlands
- Department of Translational Medicine, Section of PediatricsUniversity of Naples "Federico II"NaplesItaly
| | - Irene J. Hoogeveen
- Section of Metabolic DiseasesBeatrix Children's Hospital, University Medical Centre Groningen, University of GroningenGroningenThe Netherlands
| | - Charlotte M. A. Lubout
- Section of Metabolic DiseasesBeatrix Children's Hospital, University Medical Centre Groningen, University of GroningenGroningenThe Netherlands
| | - Foekje de Boer
- Section of Metabolic DiseasesBeatrix Children's Hospital, University Medical Centre Groningen, University of GroningenGroningenThe Netherlands
| | - Marieke J. Fokkert‐Wilts
- Section of Metabolic DiseasesBeatrix Children's Hospital, University Medical Centre Groningen, University of GroningenGroningenThe Netherlands
| | - Iris L. Rodenburg
- Section of Metabolic DiseasesBeatrix Children's Hospital, University Medical Centre Groningen, University of GroningenGroningenThe Netherlands
| | - Esther van Dam
- Section of Metabolic DiseasesBeatrix Children's Hospital, University Medical Centre Groningen, University of GroningenGroningenThe Netherlands
| | - Sarah C. Grünert
- Department of General Pediatrics, Adolescent Medicine and NeonatologyMedical Centre‐University of Freiburg, Faculty of MedicineFreiburgGermany
| | - Diego Martinelli
- Division of Metabolism, Bambino Gesù Children's HospitalIRCCSRomeItaly
| | - Maurizio Scarpa
- metabERN, Regional Center for Rare DiseasesUniversity Hospital of UdineUdineItaly
| | | | - Hanka Dekker
- VKS, The Dutch Patient Association for Inherited Metabolic DiseasesZwolleThe Netherlands
| | | | - Francjan J. van Spronsen
- Section of Metabolic DiseasesBeatrix Children's Hospital, University Medical Centre Groningen, University of GroningenGroningenThe Netherlands
| | - Terry G. J. Derks
- Section of Metabolic DiseasesBeatrix Children's Hospital, University Medical Centre Groningen, University of GroningenGroningenThe Netherlands
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Tanacan A, Gurbuz BB, Aydin E, Erden M, Coskun T, Beksac MS. Prenatal Diagnosis of Organic Acidemias at a Tertiary Center. Balkan J Med Genet 2019; 22:29-34. [PMID: 31523617 PMCID: PMC6714333 DOI: 10.2478/bjmg-2019-0003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The aim of this study was to share our experience in the prenatal diagnosis (PND) of organic acidemias (OAs) in our clinic. This study consisted of 10 cases in whom an invasive prenatal diagnostic test (IPNDT) was performed by a single physician for the PND of OAs. Median maternal age, parity, gestational week of IPNDT, prenatal test indications, OA types, method of IPNDT, IPNDT results and gestational outcomes were evaluated. Targeted mutation analysis was performed in fetal DNA for the specific mutations by using polymerase chain reaction (PCR) and direct Sanger sequencing. The diagnosis was confirmed by genetic targeted mutation analysis after birth. Median maternal age, parity and gestational week of IPNDT values were 30 (range 21-35), one (range 0-4) and 11.5 (range 11-17), respectively. Indications for IPNDT were mother being a carrier of the disease for one case (10.0%) and at least one child with OA in the family for nine cases (90.0%). Organic acidemia types investigated were maple syrup urine disease (MSUD), methylmalonic acidemia (MMA) and isovaleric acidemia (IVA) in five (50.0%), three (30.0%) and two (20.0%) patients, respectively. Chorion villus sampling (CVS) was done in seven (70.0%) patients and amniocentesis was performed in three (30.0%) patients. Eight fetuses (80.0%) were found to be healthy and two fetuses (20.0%) were found to be affected (one case with IVA and one case with MMA). The two pregnancies (20.0%) with affected fetuses were terminated. Prenatal diagnosis of OAs is critical. Appropriate prenatal counseling should be given to families with known risk factors.
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Affiliation(s)
- A Tanacan
- Department of Obstetrics and Gynecology, Division of Perinatology, Hacettepe University Hospital, Ankara, Turkey
| | - BB Gurbuz
- Department of Pediatrics, Division of Pediatric Metabolism, Hacettepe University Hospital, Ankara, Turkey
| | - E Aydin
- Department of Obstetrics and Gynecology, Division of Perinatology, Hacettepe University Hospital, Ankara, Turkey
| | - M Erden
- Department of Obstetrics and Gynecology, Division of Perinatology, Hacettepe University Hospital, Ankara, Turkey
| | - T Coskun
- Department of Pediatrics, Division of Pediatric Metabolism, Hacettepe University Hospital, Ankara, Turkey
| | - MS Beksac
- Department of Obstetrics and Gynecology, Division of Perinatology, Hacettepe University Hospital, Ankara, Turkey
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Brown LM, Corrado MM, van der Ende RM, Derks TGJ, Chen MA, Siegel S, Hoyt K, Correia CE, Lumpkin C, Flanagan TB, Carreras CT, Weinstein DA. Evaluation of glycogen storage disease as a cause of ketotic hypoglycemia in children. J Inherit Metab Dis 2015; 38:489-93. [PMID: 25070466 DOI: 10.1007/s10545-014-9744-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 06/27/2014] [Accepted: 07/03/2014] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Ketone formation is a normal response when hypoglycemia occurs. Since the majority of children with recurrent hypoglycemia cannot be diagnosed with a known endocrine or metabolic disorder on a critical sample, ketotic hypoglycemia has been described as the most common cause of low blood glucose concentrations in children. Critical samples, however, will miss the ketotic forms of glycogen storage disease (GSD), which present with elevated ketones, hypoglycemia, and normal hormonal concentrations. RESULTS A total of 164 children (96 boys, 68 girls) were enrolled in the study. Prediction of pathogenicity of DNA changes using computer modeling confirmed pathology in 20 individuals [four GSD 0, two GSD VI, 12 GSD IX alpha, one GSD IX beta, one GSD IX gamma] (12%). Boys were most likely to have changes in the PHKA2 gene, consistent with GSD IX alpha, an X-linked disorder. CONCLUSIONS Mutations in genes involved in glycogen synthesis and degradation were commonly found in children with idiopathic ketotic hypoglycemia. GSD IX is likely an unappreciated cause of ketotic hypoglycemia in children, while GSD 0 and VI are relatively uncommon. GSD IX alpha should particularly be considered in boys with unexplained hypoglycemia.
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Affiliation(s)
- Laurie M Brown
- Glycogen Storage Disease Program, Division of Pediatric Endocrinology, University of Florida College of Medicine, Box 100296, Gainesville, FL, 32610-0296, USA
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Baruteau J, Sachs P, Broué P, Brivet M, Abdoul H, Vianey-Saban C, Ogier de Baulny H. Clinical and biological features at diagnosis in mitochondrial fatty acid beta-oxidation defects: a French pediatric study of 187 patients. J Inherit Metab Dis 2013; 36:795-803. [PMID: 23053472 DOI: 10.1007/s10545-012-9542-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Revised: 08/22/2012] [Accepted: 09/11/2012] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Mitochondrial fatty acid β-oxidation defects (FAODs) are a group of severe inherited metabolic diseases, most of which can be treated with favorable prognosis following diagnosis. A description of the broad range of phenotypes resulting from these defects remains incomplete, and for this study, we sought to investigate the semiology at diagnosis in a country without a newborn screening program for FAODs. METHODS Using a retrospective French multicentre study, we analyzed 187 children aged <6 years at diagnosis with FAOD confirmed by enzymatic and/or molecular analyses. Clinical and biological parameters at diagnosis were assessed to screen liver, heart, neurological, and muscle symptoms. Information concerning the long-term prognosis was also collected. RESULTS Predominant hepatic symptoms were observed in 89 % of patients regardless of the underlying defect. The most frequent symptoms observed were hepatomegaly (92 %), increased blood alanine aminotransferase (ALAT) level (82 %), and steatosis (88 %). Other frequent features included Reye syndrome (49 %), increased gamma-glutamyltranspeptidase (GGT) (37 %), and liver failure (27 %). Extrahepatic features were often associated in the foreground. Hypoglycemia (75 %), neurological (64 %), muscle (61 %), or cardiac features (55 %) [as either cardiomyopathy (47 %) or arrhythmias (31 %)] were frequently documented. Hemodynamic events (41 %) were represented by shock (31 %) or sudden death (35 %). Hyperammonemia (73 %) and hyperlactacidemia (57 %) were the two main biochemical features. Total, very-long-chain acyl-CoA dehydrogenase (VLCADD), long-chain 3-hydroxyacylCoA dehydrogenase (LCHADD), and medium-chain acyl-CoA dehydrogenase (MCADD) deficiency mortality rates were 48 %, 60 %, 63 %, and 20 % respectively. CONCLUSION This study presents clinical features of a large cohort of patients with FAODs in a country without neonatal screening for FAODs. Our results highlight liver as the main organ involved at diagnosis regardless of age at diagnosis, classical phenotype (i.e., cardiac, hepatic, or muscular), or enzyme deficiency. Although steatosis may be observed in various inherited metabolic defects, it is a reliable indicator of FAOD and should prompt systematic screening when the diagnosis is suspected. The poor long-term prognoses reported are a strong argument for inclusion of FAODs in newborn screening programs.
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Affiliation(s)
- Julien Baruteau
- Hépatologie Pédiatrique et Maladies Métaboliques, Hôpital des Enfants-CHU Toulouse, Toulouse, France.
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Bachmann C. Interpretation of plasma amino acids in the follow-up of patients: the impact of compartmentation. J Inherit Metab Dis 2008; 31:7-20. [PMID: 18236169 DOI: 10.1007/s10545-007-0772-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2007] [Revised: 12/07/2007] [Accepted: 12/12/2007] [Indexed: 12/17/2022]
Abstract
Results of plasma or urinary amino acids are used for suspicion, confirmation or exclusion of diagnosis, monitoring of treatment, prevention and prognosis in inborn errors of amino acid metabolism. The concentrations in plasma or whole blood do not necessarily reflect the relevant metabolite concentrations in organs such as the brain or in cell compartments; this is especially the case in disorders that are not solely expressed in liver and/or in those which also affect nonessential amino acids. Basic biochemical knowledge has added much to the understanding of zonation and compartmentation of expressed proteins and metabolites in organs, cells and cell organelles. In this paper, selected old and new biochemical findings in PKU, urea cycle disorders and nonketotic hyperglycinaemia are reviewed; the aim is to show that integrating the knowledge gained in the last decades on enzymes and transporters related to amino acid metabolism allows a more extensive interpretation of biochemical results obtained for diagnosis and follow-up of patients and may help to pose new questions and to avoid pitfalls. The analysis and interpretation of amino acid measurements in physiological fluids should not be restricted to a few amino acids but should encompass the whole quantitative profile and include other pathophysiological markers. This is important if the patient appears not to respond as expected to treatment and is needed when investigating new therapies. We suggest that amino acid imbalance in the relevant compartments caused by over-zealous or protocol-driven treatment that is not adjusted to the individual patient's needs may prolong catabolism and must be corrected.
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Affiliation(s)
- Claude Bachmann
- Clinical Chemistry, University of Lausanne, Lausanne, Switzerland.
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Kasinski A, Doering CB, Danner DJ. Leucine toxicity in a neuronal cell model with inhibited branched chain amino acid catabolism. ACTA ACUST UNITED AC 2004; 122:180-7. [PMID: 15010210 DOI: 10.1016/j.molbrainres.2003.08.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2003] [Indexed: 11/20/2022]
Abstract
Individuals with the inborn error of metabolism, maple syrup urine disease (MSUD), are identified by newborn screening programs and treated with protein-modified diets that allow near normal growth and development. However, regardless of cause, a protein insult leads to metabolic decompensation, resulting in brain cell damage. The mechanism responsible for the damage is not well characterized due, in part, to the lack of an appropriate experimental model system with impaired branched chain alpha-ketoacid dehydrogenase (BCKD) activity. Here, we describe the construction of a rat pheochromocytoma cell (PC12) model harboring a doxycycline-controlled BCKD-kinase transgene. When BCKD-kinase is over-expressed in these cells, the endogenous BCKD activity is decreased, blocking branched chain amino acid (BCAA) catabolism. In cells over-expressing BCKD-kinase, addition of 25 mM leucine to the medium results in cell death. This experimental cell model accurately mimics the neuronal dysfunction in maple syrup urine disease and should facilitate further understanding of the pathophysiology of this disease and neuronal cell branched chain amino acid metabolism in general.
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Affiliation(s)
- Andrea Kasinski
- Department of Human Genetics, Emory University School of Medicine, 615 Michael St., Atlanta, GA 30322, USA
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Mick N, Brown DFM, Nadel ES. Pediatric altered mental status. J Emerg Med 2003; 25:193-6. [PMID: 12902008 DOI: 10.1016/s0736-4679(03)00176-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Nathan Mick
- Harvard Emergency Medicine Residency, Harvard Medical School, Boston, Massachusetts, USA
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Gao Z, Young RA, Li G, Najafi H, Buettger C, Sukumvanich SS, Wong RK, Wolf BA, Matschinsky FM. Distinguishing features of leucine and alpha-ketoisocaproate sensing in pancreatic beta-cells. Endocrinology 2003; 144:1949-57. [PMID: 12697702 DOI: 10.1210/en.2002-0072] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Culturing rat islets in high glucose (HG) increased 1-(14)C-alpha-ketoisocaproate (KIC) oxidation compared with culturing them in low glucose. Leucine caused insulin secretion (IS) in low glucose but not in HG rat islets, whereas KIC did so in both. Pretreatment with HG for 40 min abolished leucine stimulation of IS by mouse islets and prevented the cytosolic Ca(2+) rise without inhibiting IS and Ca(2+) increments caused by KIC. When islets were pretreated without glucose and glutamine, aminooxyacetic acid (AOA) markedly decreased KIC effects. When islets were pretreated without glucose and with glutamine, AOA potentiated leucine effects but attenuated KIC effects. AOA stimulated glutamine oxidation in the presence but not the absence of +/-2-amino-2-norbornane-carboxylic acid, a nonmetabolized leucine analog. Pretreatment with HG and glutamine partially reversed AOA inhibition of KIC effects. Glucose increased intracellular ATP and GTP, whereas it decreased ADP and GDP in beta HC9 cells. Glutamate dehydrogenase activity of beta HC9 cell extracts was increased by leucine and attenuated by GTP, but it was potentiated by ADP. In conclusion, leucine and KIC stimulated beta-cells via distinct mechanisms. Glutamate dehydrogenase is the sensor of leucine, whereas transamination plays an important role in KIC stimulation of pancreatic beta-cells.
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Affiliation(s)
- Zhiyong Gao
- Department of Pathology and Laboratory Medicine, University of Pennsylvania School of Medicine and The Children's Hospital, Philadelphia, Pennsylvania 19104, USA
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Abstract
Combined methylmalonicaciduria and homocystinuria is a disorder of intracellular cobalamin metabolism that remains a challenge to the physician unfamiliar with the diagnosis. We have followed six patients with combined methylmalonicaciduria and homocystinuria (four males, two females, age 4.2-24 years) for a median of 6.5 years (range 4-9 years). Age at diagnosis was between 18 days and 14 months in early-onset cases (n = 4) and 15 and 19 years in late-onset cases. Predominant clinical features include microcephaly, hydrocephalus, seizures, and white-matter changes on magnetic resonance imaging in early-onset cases. The white-matter changes may be secondary to impaired methylation owing to a lack of readily available methyl groups. Spastic quadriparesis and diplegia are long-term sequelae in late-onset cases. Management consists of hydroxycobalamin intramuscular injections, oral folate, betaine, and carnitine supplementation. Dietary protein restriction may be necessary when metabolic control remains difficult. The implementation of an emergency regimen should alleviate episodes of metabolic decompensation and reduce the rate of hospital admissions.
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Affiliation(s)
- Debra L Smith
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
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Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr 2002. [PMID: 11841046 DOI: 10.1177/0148607102026001011] [Citation(s) in RCA: 468] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Nicolaides P, Liebsch D, Dale N, Leonard J, Surtees R. Neurological outcome of patients with ornithine carbamoyltransferase deficiency. Arch Dis Child 2002; 86:54-6. [PMID: 11806886 PMCID: PMC1719070 DOI: 10.1136/adc.86.1.54] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Ornithine carbamoyltransferase (OCT) deficiency is the commonest of the inherited urea cycle disorders. AIMS To determine the long term neurological and cognitive outcome of continuously treated surviving patients. METHODS Twenty eight surviving children (five boys) with OCT deficiency who had been treated continuously with a low protein diet and alternative pathway therapy were identified. Those aged 5-16 years had a detailed neurological examination and psychometric testing. RESULTS Four presented in the neonatal period and four were treated prospectively following antenatal diagnosis. Median (range) age at diagnosis for the later onset group was 19 (2-144) months; median time between onset of symptoms and diagnosis was 10 (2-48) months. Nine children had had less than three episodes of hyperammonaemic encephalopathy, the others more. Seven had focal abnormalities on neurological examination; 14 had global cognitive impairment; four had a normal IQ but specific learning difficulties. Sixteen underwent neuroimaging which was normal in three, showed focal abnormalities of the cerebral hemispheres in six, and global cerebral atrophy in seven. CONCLUSION Eighteen of 28 surviving children with OCT deficiency had disabling neurological complications. Plasma ammonia at diagnosis was the only factor that predicted this outcome. While most neurological complications could be attributed to hyperammonaemic encephalopathy, other mechanisms may also contribute to the neurological abnormalities.
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Affiliation(s)
- P Nicolaides
- Neurodisability Service, Great Ormond Street Hospital for Children NHS Trust, The Wolfson Centre, Mecklenburgh Square, London WC1N 2AP, UK
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Abstract
Diet is one of the mainstays of the treatment of patients with urea cycle disorders. The protein intake should be adjusted to take account of the inborn error and its severity and the patient's age, growth rate, and individual preferences. Currently, the widely used standards for protein intake are probably more generous than necessary, particularly for those with the more severe variants. Most patients, except those with arginase deficiency, will need supplements of arginine, but the value of other supplements including citrate and carnitine is unclear. Any patient on a low-protein diet should be monitored clinically and with appropriate laboratory tests. All should have an emergency (crisis) regimen to prevent decompensation during periods of metabolic stress.
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Affiliation(s)
- J V Leonard
- Institute of Child Health and Great Ormond Street Hospital for Children, London, United Kingdom
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Wilson CJ, Champion MP, Collins JE, Clayton PT, Leonard JV. Outcome of medium chain acyl-CoA dehydrogenase deficiency after diagnosis. Arch Dis Child 1999; 80:459-62. [PMID: 10208954 PMCID: PMC1717923 DOI: 10.1136/adc.80.5.459] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Medium chain acyl-CoA dehydrogenase (MCAD) deficiency is the most common inborn error of fatty acid metabolism. Undiagnosed, it has a mortality rate of 20-25%. Neonatal screening for the disorder is now possible but it is not known whether this would alter the prognosis. OBJECTIVE To investigate the outcome of MCAD deficiency after the diagnosis has been established. METHOD All patients with a proved diagnosis of MCAD deficiency attending one centre in a four year period were reviewed. RESULTS Forty one patients were identified. Follow up was for a median of 6.7 years (range, 9 months to 14 years). Nearly half of the patients were admitted to hospital with symptoms characteristic of MCAD deficiency before the correct diagnosis was made. After diagnosis, two patients were admitted to hospital with severe encephalopathy but there were no additional deaths or appreciable morbidity. There was a high incidence (about one fifth) of previous sibling deaths among the cohort. CONCLUSIONS Undiagnosed, MCAD deficiency results in considerable mortality and morbidity. However, current management improves outcome, supporting the view that the disorder should be included in newborn screening programmes.
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Affiliation(s)
- C J Wilson
- Metabolic Unit, Great Ormond Street Hospital for Children, Great Ormond Street, London WC1N 3JH, UK.
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