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Adams AD, Fiesco-Roa MÓ, Wong L, Jenkins GP, Malinowski J, Demarest OM, Rothberg PG, Hobert JA. Phenylalanine hydroxylase deficiency treatment and management: A systematic evidence review of the American College of Medical Genetics and Genomics (ACMG). Genet Med 2023; 25:100358. [PMID: 37470789 DOI: 10.1016/j.gim.2022.12.005] [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: 12/05/2022] [Revised: 12/08/2022] [Accepted: 12/08/2022] [Indexed: 07/21/2023] Open
Abstract
PURPOSE Elevated serum phenylalanine (Phe) levels due to biallelic pathogenic variants in phenylalanine hydroxylase (PAH) may cause neurodevelopmental disorders or birth defects from maternal phenylketonuria. New Phe reduction treatments have been approved in the last decade, but uncertainty on the optimal lifespan goal Phe levels for patients with PAH deficiency remains. METHODS We searched Medline and Embase for evidence of treatment concerning PAH deficiency up to September 28, 2021. Risk of bias was evaluated based on study design. Random-effects meta-analyses were performed to compare IQ, gestational outcomes, and offspring outcomes based on Phe ≤ 360 μmol/L vs > 360 μmol/L and reported as odds ratio and 95% CI. Remaining results were narratively synthesized. RESULTS A total of 350 studies were included. Risk of bias was moderate. Lower Phe was consistently associated with better outcomes. Achieving Phe ≤ 360 μmol/L before conception substantially lowered the risk of negative effect to offspring in pregnant individuals (odds ratio = 0.07, 95% CI = 0.04-0.14; P < .0001). Adverse events due to pharmacologic treatment were common, but medication reduced Phe levels, enabling dietary liberalization. CONCLUSIONS Reduction of Phe levels to ≤360 μmol/L through diet or medication represents effective interventions to treat PAH deficiency.
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Affiliation(s)
- April D Adams
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX; Division of Maternal-Fetal Medicine, Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | - Moisés Ó Fiesco-Roa
- Programa de Maestría y Doctorado en Ciencias Médicas, Universidad Nacional Autónoma de México (UNAM), Mexico City, Mexico; Laboratorio de Citogenética, Instituto Nacional de Pediatría, Mexico City, Mexico
| | | | | | | | | | - Paul G Rothberg
- Department of Pathology & Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
| | - Judith A Hobert
- University of Utah School of Medicine, Salt Lake City, UT; ARUP Laboratories, Salt Lake City, UT
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Suitability and Allocation of Protein-Containing Foods According to Protein Tolerance in PKU: A 2022 UK National Consensus. Nutrients 2022; 14:nu14234987. [PMID: 36501017 PMCID: PMC9736047 DOI: 10.3390/nu14234987] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 11/15/2022] [Accepted: 11/17/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction: There is little practical guidance about suitable food choices for higher natural protein tolerances in patients with phenylketonuria (PKU). This is particularly important to consider with the introduction of adjunct pharmaceutical treatments that may improve protein tolerance. Aim: To develop a set of guidelines for the introduction of higher protein foods into the diets of patients with PKU who tolerate >10 g/day of protein. Methods: In January 2022, a 26-item food group questionnaire, listing a range of foods containing protein from 5 to >20 g/100 g, was sent to all British Inherited Metabolic Disease Group (BIMDG) dietitians (n = 80; 26 Inherited Metabolic Disease [IMD] centres). They were asked to consider within their IMD dietetic team when they would recommend introducing each of the 26 protein-containing food groups into a patient’s diet who tolerated >10 g to 60 g/day of protein. The patient protein tolerance for each food group that received the majority vote from IMD dietetic teams was chosen as its tolerance threshold for introduction. A virtual meeting was held using Delphi methodology in March 2022 to discuss and agree final consensus. Results: Responses were received from dietitians from 22/26 IMD centres (85%) (11 paediatric, 11 adult). For patients tolerating protein ≥15 g/day, the following foods were agreed for inclusion: gluten-free pastas, gluten-free flours, regular bread, cheese spreads, soft cheese, and lentils in brine; for protein tolerance ≥20 g/day: nuts, hard cheeses, regular flours, meat/fish, and plant-based alternative products (containing 5−10 g/100 g protein), regular pasta, seeds, eggs, dried legumes, and yeast extract spreads were added; for protein tolerance ≥30 g/day: meat/fish and plant-based alternative products (containing >10−20 g/100 g protein) were added; and for protein tolerance ≥40 g/day: meat/fish and plant-based alternatives (containing >20 g/100 g protein) were added. Conclusion: This UK consensus by IMD dietitians from 22 UK centres describes for the first time the suitability and allocation of higher protein foods according to individual patient protein tolerance. It provides valuable guidance for health professionals to enable them to standardize practice and give rational advice to patients.
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McWhorter N, Ndugga-Kabuye MK, Puurunen M, Ernst SL. Complications of the Low Phenylalanine Diet for Patients with Phenylketonuria and the Benefits of Increased Natural Protein. Nutrients 2022; 14:4960. [PMID: 36500989 PMCID: PMC9740314 DOI: 10.3390/nu14234960] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/18/2022] [Accepted: 11/21/2022] [Indexed: 11/24/2022] Open
Abstract
Phenylketonuria (PKU) is an inherited disorder in which phenylalanine (Phe) is not correctly metabolized leading to an abnormally high plasma Phe concentration that causes profound neurologic damage if left untreated. The mainstay of treatment for PKU has centered around limiting natural protein in the diet while supplementing with medical foods in order to prevent neurologic injury while promoting growth. This review discusses several deleterious effects of the low Phe diet along with benefits that have been reported for patients with increased natural protein intake while maintaining plasma Phe levels within treatment guidelines.
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Evers RAF, van Wegberg AMJ, MacDonald A, Huijbregts SCJ, Leuzzi V, van Spronsen FJ. Dietary Liberalization in Tetrahydrobiopterin-Treated PKU Patients: Does It Improve Outcomes? Nutrients 2022; 14:3874. [PMID: 36145250 PMCID: PMC9504284 DOI: 10.3390/nu14183874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/23/2022] Open
Abstract
PURPOSE this systematic review aimed to assess the effects of dietary liberalization following tetrahydrobiopterin (BH4) treatment on anthropometric measurements, nutritional biomarkers, quality of life, bone density, mental health and psychosocial functioning, and burden of care in PKU patients. METHODS the PubMed, Cochrane, and Embase databases were searched on 7 April 2022. We included studies that reported on the aforementioned domains before and after dietary liberalization as a result of BH4 treatment in PKU patients. Exclusion criteria were: studies written in a language other than English; studies that only included data of a BH4 loading test; insufficient data for the parameters of interest; and wrong publication type. Both within-subject and between-subject analyses were assessed, and meta-analyses were performed if possible. RESULTS twelve studies containing 14 cohorts and 228 patients were included. Single studies reported few significant differences. Two out of fifteen primary meta-analyses were significant; BMI was higher in BH4-treated patients versus controls (p = 0.02; standardized mean difference (SMD) (95% confidence interval (CI)) = -0.37 (-0.67, -0.06)), and blood cholesterol concentrations increased after starting BH4 treatment (p = 0.01; SMD (CI) = -0.70 (-1.26, -0.15)). CONCLUSION there is no clear evidence that dietary liberalization after BH4 treatment has a positive effect on anthropometric measurements, nutritional biomarkers, or quality of life. No studies could be included for bone density, mental health and psychosocial functioning, and burden of care.
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Affiliation(s)
- Roeland A. F. Evers
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, 9700 RB Groningen, The Netherlands
| | - Annemiek M. J. van Wegberg
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, 9700 RB Groningen, The Netherlands
| | - Anita MacDonald
- Dietetic Department, Birmingham Children’s Hospital, Birmingham B4 6NH, UK
| | - Stephan C. J. Huijbregts
- Department of Clinical Child and Adolescent Studies-Neurodevelopmental Disorders, Faculty of Social Sciences, Leiden University, 2300 RB Leiden, The Netherlands
| | - Vincenzo Leuzzi
- Unit of Child Neurology and Psychiatry, Department of Human Neuroscience, Sapienza University of Rome, 00185 Rome, Italy
| | - Francjan J. van Spronsen
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, 9700 RB Groningen, The Netherlands
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Ilgaz F, Marsaux C, Pinto A, Singh R, Rohde C, Karabulut E, Gökmen-Özel H, Kuhn M, MacDonald A. Protein Substitute Requirements of Patients with Phenylketonuria on BH4 Treatment: A Systematic Review and Meta-Analysis. Nutrients 2021; 13:1040. [PMID: 33807079 PMCID: PMC8004763 DOI: 10.3390/nu13031040] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/12/2021] [Accepted: 03/19/2021] [Indexed: 11/16/2022] Open
Abstract
The traditional treatment for phenylketonuria (PKU) is a phenylalanine (Phe)-restricted diet, supplemented with a Phe-free/low-Phe protein substitute. Pharmaceutical treatment with synthetic tetrahydrobiopterin (BH4), an enzyme cofactor, allows a patient subgroup to relax their diet. However, dietary protocols guiding the adjustments of protein equivalent intake from protein substitute with BH4 treatment are lacking. We systematically reviewed protein substitute usage with long-term BH4 therapy. Electronic databases were searched for articles published between January 2000 and March 2020. Eighteen studies (306 PKU patients) were eligible. Meta-analyses demonstrated a significant increase in Phe and natural protein intakes and a significant decrease in protein equivalent intake from protein substitute with cofactor therapy. Protein substitute could be discontinued in 51% of responsive patients, but was still required in 49%, despite improvement in Phe tolerance. Normal growth was maintained, but micronutrient deficiency was observed with BH4 treatment. A systematic protocol to increase natural protein intake while reducing protein substitute dose should be followed to ensure protein and micronutrient requirements are met and sustained. We propose recommendations to guide healthcare professionals when adjusting dietary prescriptions of PKU patients on BH4. Studies investigating new therapeutic options in PKU should systematically collect data on protein substitute and natural protein intakes, as well as other nutritional factors.
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Affiliation(s)
- Fatma Ilgaz
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Hacettepe University, 06100 Ankara, Turkey; (F.I.); (H.G.-Ö.)
| | - Cyril Marsaux
- Danone Nutricia Research, 3584CT Utrecht, The Netherlands;
| | - Alex Pinto
- Department of Dietetics, Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (A.P.); (A.M.)
| | - Rani Singh
- Metabolic Genetics Nutrition Program, Department of Human Genetics, Emory University, Atlanta, GA 30322, USA;
| | - Carmen Rohde
- Department of Paediatrics of the University Clinics Leipzig, University of Leipzig, 04103 Leipzig, Germany;
| | - Erdem Karabulut
- Department of Biostatistics, Faculty of Medicine, Hacettepe University, 06100 Ankara, Turkey;
| | - Hülya Gökmen-Özel
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Hacettepe University, 06100 Ankara, Turkey; (F.I.); (H.G.-Ö.)
| | - Mirjam Kuhn
- Danone Nutricia Research, 3584CT Utrecht, The Netherlands;
| | - Anita MacDonald
- Department of Dietetics, Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (A.P.); (A.M.)
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Cognitive analysis of metabolomics data for systems biology. Nat Protoc 2021; 16:1376-1418. [PMID: 33483720 DOI: 10.1038/s41596-020-00455-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 10/27/2020] [Indexed: 01/30/2023]
Abstract
Cognitive computing is revolutionizing the way big data are processed and integrated, with artificial intelligence (AI) natural language processing (NLP) platforms helping researchers to efficiently search and digest the vast scientific literature. Most available platforms have been developed for biomedical researchers, but new NLP tools are emerging for biologists in other fields and an important example is metabolomics. NLP provides literature-based contextualization of metabolic features that decreases the time and expert-level subject knowledge required during the prioritization, identification and interpretation steps in the metabolomics data analysis pipeline. Here, we describe and demonstrate four workflows that combine metabolomics data with NLP-based literature searches of scientific databases to aid in the analysis of metabolomics data and their biological interpretation. The four procedures can be used in isolation or consecutively, depending on the research questions. The first, used for initial metabolite annotation and prioritization, creates a list of metabolites that would be interesting for follow-up. The second workflow finds literature evidence of the activity of metabolites and metabolic pathways in governing the biological condition on a systems biology level. The third is used to identify candidate biomarkers, and the fourth looks for metabolic conditions or drug-repurposing targets that the two diseases have in common. The protocol can take 1-4 h or more to complete, depending on the processing time of the various software used.
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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.
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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
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van Vliet K, Rodenburg IL, van Ginkel WG, Lubout CMA, Wolffenbuttel BHR, van der Klauw MM, Heiner-Fokkema MR, van Spronsen FJ. Biomarkers of Micronutrients in Regular Follow-Up for Tyrosinemia Type 1 and Phenylketonuria Patients. Nutrients 2019; 11:E2011. [PMID: 31461828 PMCID: PMC6769775 DOI: 10.3390/nu11092011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 08/16/2019] [Accepted: 08/21/2019] [Indexed: 12/26/2022] Open
Abstract
Phenylketonuria (PKU) is treated with dietary restrictions and sometimes tetrahydrobiopterin (BH4). PKU patients are at risk for developing micronutrient deficiencies, such as vitamin B12 and folic acid, likely due to their diet. Tyrosinemia type 1 (TT1) is similar to PKU in both pathogenesis and treatment. TT1 patients follow a similar diet, but nutritional deficiencies have not been investigated yet. In this retrospective study, biomarkers of micronutrients in TT1 and PKU patients were investigated and outcomes were correlated to dietary intake and anthropometric measurements from regular follow-up measurements from patients attending the outpatient clinic. Data was analyzed using Kruskal-Wallis, Fisher's exact and Spearman correlation tests. Furthermore, descriptive data were used. Overall, similar results for TT1 and PKU patients (with and without BH4) were observed. In all groups high vitamin B12 concentrations were seen rather than B12 deficiencies. Furthermore, all groups showed biochemical evidence of vitamin D deficiency. This study shows that micronutrients in TT1 and PKU patients are similar and often within the normal ranges and that vitamin D concentrations could be optimized.
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Affiliation(s)
- Kimber van Vliet
- Division of Metabolic Diseases, Groningen, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Iris L Rodenburg
- Division of Metabolic Diseases, Groningen, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Willem G van Ginkel
- Division of Metabolic Diseases, Groningen, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Charlotte M A Lubout
- Division of Metabolic Diseases, Groningen, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Bruce H R Wolffenbuttel
- Department of Endocrinology, Groningen, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Melanie M van der Klauw
- Department of Endocrinology, Groningen, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - M Rebecca Heiner-Fokkema
- Laboratory of Metabolic Diseases, Groningen, Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Francjan J van Spronsen
- Division of Metabolic Diseases, Groningen, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands.
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