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Barros CDS, Coutinho A, Tengan CH. Arginine Supplementation in MELAS Syndrome: What Do We Know about the Mechanisms? Int J Mol Sci 2024; 25:3629. [PMID: 38612442 PMCID: PMC11011289 DOI: 10.3390/ijms25073629] [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: 02/23/2024] [Revised: 03/20/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
MELAS syndrome, characterized by mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes, represents a devastating mitochondrial disease, with the stroke-like episodes being its primary manifestation. Arginine supplementation has been used and recommended as a treatment for these acute attacks; however, insufficient evidence exists to support this treatment for MELAS. The mechanisms underlying the effect of arginine on MELAS pathophysiology remain unclear, although it is hypothesized that arginine could increase nitric oxide availability and, consequently, enhance blood supply to the brain. A more comprehensive understanding of these mechanisms is necessary to improve treatment strategies, such as dose and regimen adjustments; identify which patients could benefit the most; and establish potential markers for follow-up. This review aims to analyze the existing evidence concerning the mechanisms through which arginine supplementation impacts MELAS pathophysiology and provide the current scenario and perspectives for future investigations.
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Affiliation(s)
| | | | - Celia H. Tengan
- Division of Neurology, Department of Neurology and Neurosurgery, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo 04039-032, Brazil; (C.D.S.B.); (A.C.)
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2
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Ng YS, McFarland R. Mitochondrial encephalomyopathy. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:563-585. [PMID: 37562887 DOI: 10.1016/b978-0-323-98818-6.00025-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Mitochondrial dysfunction, especially perturbation of oxidative phosphorylation and adenosine triphosphate (ATP) generation, disrupts cellular homeostasis and is a surprisingly frequent cause of central and peripheral nervous system pathology. Mitochondrial disease is an umbrella term that encompasses a host of clinical syndromes and features caused by in excess of 300 different genetic defects affecting the mitochondrial and nuclear genomes. Patients with mitochondrial disease can present at any age, ranging from neonatal onset to late adult life, with variable organ involvement and neurological manifestations including neurodevelopmental delay, seizures, stroke-like episodes, movement disorders, optic neuropathy, myopathy, and neuropathy. Until relatively recently, analysis of skeletal muscle biopsy was the focus of diagnostic algorithms, but step-changes in the scope and availability of next-generation sequencing technology and multiomics analysis have revolutionized mitochondrial disease diagnosis. Currently, there is no specific therapy for most types of mitochondrial disease, although clinical trials research in the field is gathering momentum. In that context, active management of epilepsy, stroke-like episodes, dystonia, brainstem dysfunction, and Parkinsonism are all the more important in improving patient quality of life and reducing mortality.
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Affiliation(s)
- Yi Shiau Ng
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.
| | - Robert McFarland
- NHS Highly Specialised Service for Rare Mitochondrial Disorders, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
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3
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Stefanetti R, Ng Y, Errington L, Blain A, McFarland R, Gorman GS. L-arginine in Mitochondrial Encephalopathy, Lactic Acidosis, and Stroke-like Episodes: A Systematic Review. Neurology 2022; 98:e2318-e2328. [PMID: 35428733 PMCID: PMC9202525 DOI: 10.1212/wnl.0000000000200299] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 02/15/2022] [Indexed: 12/02/2022] Open
Abstract
Background and Objectives Stroke management in the context of primary mitochondrial disease is clinically challenging, and the best treatment options for patients with stroke-like episodes remain uncertain. We sought to perform a systematic review of the safety and efficacy of l-arginine use in the acute and prophylactic management of stroke-like episodes in patients with mitochondrial disease. Methods The systematic review was registered in PROSPERO (CRD42020181230). We searched 6 databases from inception to January 15, 2021: MEDLINE, Embase, Scopus, Web of Science, CINAHL, and ClinicalTrials.gov. Original articles and registered trials available, in English, reporting l-arginine use in the acute or prophylactic management of stroke-like episodes in patients with genetically confirmed mitochondrial disease were eligible for inclusion. Data on safety and treatment response were extracted and summarized by multiple observers. Risk of bias was assessed by the methodologic quality of case reports, case series, and a risk-of-bias checklist for nonrandomized studies. Quality of evidence was synthesized with the Oxford Centre for Evidence-Based Medicine Levels of Evidence and Grade of Recommendations. The predetermined main outcome measures were clinical response to l-arginine treatment, adverse events, withdrawals, and deaths (on treatment and/or during follow-up), as defined by the author. Results Thirty-seven articles met inclusion criteria (0 randomized controlled trials; 3 open-label; 1 retrospective cohort; 33 case reports/case series) (N = 91 patients; 86% m.3243A>G). In the case reports, 54% of patients reported a positive clinical response to acute l-arginine, of which 40% were concomitantly treated with antiepileptic drugs. Improved headache at 24 hours was the greatest reported benefit in response to IV l-arginine in the open-label trials (31 of 39, 79%). In 15 of 48 patients (31%) who positively responded to prophylactic l-arginine, antiepileptic drugs were either used (7 of 15) or unreported (8 of 15). Moderate adverse events were reported in the follow-up of both IV and oral l-arginine treatment, and 11 patients (12%) died during follow-up or while on prophylactic treatment. Discussion The available evidence is of poor methodologic quality and classified as Level 5. IV and oral l-arginine confers no demonstrable clinical benefit in either the acute or prophylactic treatment of mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes, with more robust controlled trials required to assess its efficacy and safety profile.
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4
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Mastrangelo M, Ricciardi G, Giordo L, Michele MD, Toni D, Leuzzi V. Stroke and stroke-like episodes in inborn errors of metabolism: Pathophysiological and clinical implications. Mol Genet Metab 2022; 135:3-14. [PMID: 34996714 DOI: 10.1016/j.ymgme.2021.12.014] [Citation(s) in RCA: 7] [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: 10/08/2021] [Revised: 11/19/2021] [Accepted: 12/18/2021] [Indexed: 10/19/2022]
Abstract
Inborn errors of metabolism causing stroke (ischemic or haemorrhagic) or stroke-like episodes (e.g., that are also called "metabolic strokes" and include acute brain lesions not related with alterations of blood flow) cover a wide range of diseases in which acute metabolic decompensations after trigger events (e.g., fever, dehydration, sepsis etc.) may have a variable frequency. The early diagnosis of these conditions is essential because, despite their rarity, effective symptomatic treatments may be available for acute settings (e.g., arginine for Mitochondrial myopathy, Encephalopathy, Lactic Acidosis, and Stroke-like episodes- MELAS) while in other cases disease modifying therapies may be useful to prevent stroke occurrence, recurrence, or relapse (e.g., Fabry disease). The detection of a non-vascular distribution of lesions and the diffuse use of 1HMRS are often diriment in the differential of ischemic and metabolic strokes. This review summarized the main clinical features and the pathophysiological mechanisms of stroke and stroke-like episodes in inborn errors of metabolism presenting with stroke as part of natural history of the disease. These conditions belong to different etiological groups, such as organic acidurias, mitochondrial encephalopathies, homocystinuria and remethylation disorders, urea cycle disorders, lysosomal diseases (e.g. Fabry disease, glycogen storage disease), congenital disorders of glycosylation, neurotransmitter disorders, adenosine deaminase 2 deficiency and few other neurometabolic disorders.
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Affiliation(s)
- Mario Mastrangelo
- Child Neurology and Psychiatry Unit - Department of Human Neuroscience-Sapienza, Università di Roma, Italy
| | - Giacomina Ricciardi
- Child Neurology and Psychiatry Unit - Department of Human Neuroscience-Sapienza, Università di Roma, Italy
| | - Laura Giordo
- Child Neurology and Psychiatry Unit - Department of Human Neuroscience-Sapienza, Università di Roma, Italy
| | - Manuela De Michele
- Emergency Department Stroke Unit, Department of Human Neuroscience, Sapienza, Università di Roma, Italy
| | - Danilo Toni
- Emergency Department Stroke Unit, Department of Human Neuroscience, Sapienza, Università di Roma, Italy
| | - Vincenzo Leuzzi
- Child Neurology and Psychiatry Unit - Department of Human Neuroscience-Sapienza, Università di Roma, Italy.
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5
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Cucchiara BL, Kasner SE. Treatment of “Other” Stroke Etiologies. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00058-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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6
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Almannai M, El-Hattab AW. Nitric Oxide Deficiency in Mitochondrial Disorders: The Utility of Arginine and Citrulline. Front Mol Neurosci 2021; 14:682780. [PMID: 34421535 PMCID: PMC8374159 DOI: 10.3389/fnmol.2021.682780] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/21/2021] [Indexed: 11/21/2022] Open
Abstract
Mitochondrial diseases represent a growing list of clinically heterogeneous disorders that are associated with dysfunctional mitochondria and multisystemic manifestations. In spite of a better understanding of the underlying pathophysiological basis of mitochondrial disorders, treatment options remain limited. Over the past two decades, there is growing evidence that patients with mitochondrial disorders have nitric oxide (NO) deficiency due to the limited availability of NO substrates, arginine and citrulline; decreased activity of nitric oxide synthase (NOS); and NO sequestration. Studies evaluating the use of arginine in patients with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) presenting with stroke-like episodes showed symptomatic improvement after acute administration as well as a reduction in the frequency and severity of stroke-like episodes following chronic use. Citrulline, another NO precursor, was shown through stable isotope studies to result in a greater increase in NO synthesis. Recent studies showed a positive response of arginine and citrulline in other mitochondrial disorders besides MELAS. Randomized-controlled studies with a larger number of patients are warranted to better understand the role of NO deficiency in mitochondrial disorders and the efficacy of NO precursors as treatment modalities in these disorders.
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Affiliation(s)
- Mohammed Almannai
- Section of Medical Genetics, Children's Hospital, King Fahad Medical City, Riyadh, Saudi Arabia.,College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ayman W El-Hattab
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates.,Clinical Genetics, University Hospital Sharjah, Sharjah, United Arab Emirates
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7
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The Role of Taurine in Mitochondria Health: More Than Just an Antioxidant. Molecules 2021; 26:molecules26164913. [PMID: 34443494 PMCID: PMC8400259 DOI: 10.3390/molecules26164913] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 08/08/2021] [Accepted: 08/10/2021] [Indexed: 12/21/2022] Open
Abstract
Taurine is a naturally occurring sulfur-containing amino acid that is found abundantly in excitatory tissues, such as the heart, brain, retina and skeletal muscles. Taurine was first isolated in the 1800s, but not much was known about this molecule until the 1990s. In 1985, taurine was first approved as the treatment among heart failure patients in Japan. Accumulating studies have shown that taurine supplementation also protects against pathologies associated with mitochondrial defects, such as aging, mitochondrial diseases, metabolic syndrome, cancer, cardiovascular diseases and neurological disorders. In this review, we will provide a general overview on the mitochondria biology and the consequence of mitochondrial defects in pathologies. Then, we will discuss the antioxidant action of taurine, particularly in relation to the maintenance of mitochondria function. We will also describe several reported studies on the current use of taurine supplementation in several mitochondria-associated pathologies in humans.
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8
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Vassar R, Mehta N. Pearls & Oy-sters: Symmetric Numbness and Paresthesia Due to Stroke-like Episode in an Adolescent Male With MELAS. Neurology 2021; 97:1006-1008. [PMID: 34376513 DOI: 10.1212/wnl.0000000000012611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Mitochondrial Encephalopathy, Lactic Acidosis, and Stroke-like episodes (MELAS) syndrome is a mitochondrial condition with a wide range of neurologic complications including migraines, seizures, and stroke-like episodes. This case report highlights a rare presentation of bilateral sensory changes related to MELAS and offers an opportunity to consider how a differential diagnosis may need to be modified in patients with underlying mitochondrial disorders. Neurologic symptoms in MELAS may defy classic localization patterns, and early neuroimaging is warranted.
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Affiliation(s)
- Rachel Vassar
- Child Neurology Residency Program, Department of Neurology, University of California San Francisco, San Francisco, CA
| | - Nehali Mehta
- Child Neurology Residency Program, Department of Neurology, University of California San Francisco, San Francisco, CA
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9
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Tinker RJ, Lim AZ, Stefanetti RJ, McFarland R. Current and Emerging Clinical Treatment in Mitochondrial Disease. Mol Diagn Ther 2021; 25:181-206. [PMID: 33646563 PMCID: PMC7919238 DOI: 10.1007/s40291-020-00510-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2020] [Indexed: 12/11/2022]
Abstract
Primary mitochondrial disease (PMD) is a group of complex genetic disorders that arise due to pathogenic variants in nuclear or mitochondrial genomes. Although PMD is one of the most prevalent inborn errors of metabolism, it often exhibits marked phenotypic variation and can therefore be difficult to recognise. Current treatment for PMD revolves around supportive and preventive approaches, with few disease-specific therapies available. However, over the last decade there has been considerable progress in our understanding of both the genetics and pathophysiology of PMD. This has resulted in the development of a plethora of new pharmacological and non-pharmacological therapies at varying stages of development. Many of these therapies are currently undergoing clinical trials. This review summarises the latest emerging therapies that may become mainstream treatment in the coming years. It is distinct from other recent reviews in the field by comprehensively addressing both pharmacological non-pharmacological therapy from both a bench and a bedside perspective. We highlight the current and developing therapeutic landscape in novel pharmacological treatment, dietary supplementation, exercise training, device use, mitochondrial donation, tissue replacement gene therapy, hypoxic therapy and mitochondrial base editing.
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Affiliation(s)
- Rory J Tinker
- Wellcome Centre for Mitochondrial Research, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
- Clinical and Translational Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Albert Z Lim
- Wellcome Centre for Mitochondrial Research, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
- Clinical and Translational Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Renae J Stefanetti
- Wellcome Centre for Mitochondrial Research, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
- Clinical and Translational Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Robert McFarland
- Wellcome Centre for Mitochondrial Research, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK.
- Clinical and Translational Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK.
- NHS Highly Specialised Service for Rare Mitochondrial Disorders for Adults and Children, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
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10
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Minakawa EN, Nagai Y. Protein Aggregation Inhibitors as Disease-Modifying Therapies for Polyglutamine Diseases. Front Neurosci 2021; 15:621996. [PMID: 33642983 PMCID: PMC7907447 DOI: 10.3389/fnins.2021.621996] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 01/18/2021] [Indexed: 12/11/2022] Open
Abstract
The polyglutamine (polyQ) diseases are a group of inherited neurodegenerative diseases caused by the abnormal expansion of a CAG trinucleotide repeat that are translated into an expanded polyQ stretch in the disease-causative proteins. The expanded polyQ stretch itself plays a critical disease-causative role in the pathomechanisms underlying polyQ diseases. Notably, the expanded polyQ stretch undergoes a conformational transition from the native monomer into the β-sheet-rich monomer, followed by the formation of soluble oligomers and then insoluble aggregates with amyloid fibrillar structures. The intermediate soluble species including the β-sheet-rich monomer and oligomers exhibit substantial neurotoxicity. Therefore, protein conformation stabilization and aggregation inhibition that target the upstream of the insoluble aggregate formation would be a promising approach toward the development of disease-modifying therapies for polyQ diseases. PolyQ aggregation inhibitors of different chemical categories, such as intrabodies, peptides, and small chemical compounds, have been identified through intensive screening methods. Among them, recent advances in the brain delivery methods of several peptides and the screening of small chemical compounds have brought them closer to clinical utility. Notably, the recent discovery of arginine as a potent conformation stabilizer and aggregation inhibitor of polyQ proteins both in vitro and in vivo have paved way to the clinical trial for the patients with polyQ diseases. Meanwhile, expression reduction of expanded polyQ proteins per se would be another promising approach toward disease modification of polyQ diseases. Gene silencing, especially by antisense oligonucleotides (ASOs), have succeeded in reducing the expression of polyQ proteins in the animal models of various polyQ diseases by targeting the aberrant mRNA with expanded CAG repeats. Of note, some of these ASOs have recently been translated into clinical trials. Here we overview and discuss these recent advances toward the development of disease modifying therapies for polyQ diseases. We envision that combination therapies using aggregation inhibitors and gene silencing would meet the needs of the patients with polyQ diseases and their caregivers in the near future to delay or prevent the onset and progression of these currently intractable diseases.
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Affiliation(s)
- Eiko N Minakawa
- Department of Degenerative Neurological Diseases, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira, Japan
| | - Yoshitaka Nagai
- Department of Degenerative Neurological Diseases, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira, Japan.,Department of Neurotherapeutics, Osaka University Graduate School of Medicine, Suita, Japan
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11
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L-Arginine Reduces Nitro-Oxidative Stress in Cultured Cells with Mitochondrial Deficiency. Nutrients 2021; 13:nu13020534. [PMID: 33562042 PMCID: PMC7914615 DOI: 10.3390/nu13020534] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/26/2021] [Accepted: 02/03/2021] [Indexed: 12/16/2022] Open
Abstract
L-Arginine (L-ARG) supplementation has been suggested as a therapeutic option in several diseases, including Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-like syndrome (MELAS), arguably the most common mitochondrial disease. It is suggested that L-ARG, a nitric oxide (NO) precursor, can restore NO levels in blood vessels, improving cerebral blood flow. However, NO also participates in mitochondrial processes, such as mitochondrial biogenesis, the regulation of the respiratory chain, and oxidative stress. This study investigated the effects of L-ARG on mitochondrial function, nitric oxide synthesis, and nitro-oxidative stress in cell lines harboring the MELAS mitochondrial DNA (mtDNA) mutation (m.3243A>G). We evaluated mitochondrial enzyme activity, mitochondrial mass, NO concentration, and nitro-oxidative stress. Our results showed that m.3243A>G cells had increased NO levels and protein nitration at basal conditions. Treatment with L-ARG did not affect the mitochondrial function and mass but reduced the intracellular NO concentration and nitrated proteins in m.3243A>G cells. The same treatment led to opposite effects in control cells. In conclusion, we showed that the main effect of L-ARG was on protein nitration. Lowering protein nitration is probably involved in the mechanism related to L-ARG supplementation benefits in MELAS patients.
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12
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Minakawa EN, Popiel HA, Tada M, Takahashi T, Yamane H, Saitoh Y, Takahashi Y, Ozawa D, Takeda A, Takeuchi T, Okamoto Y, Yamamoto K, Suzuki M, Fujita H, Ito C, Yagihara H, Saito Y, Watase K, Adachi H, Katsuno M, Mochizuki H, Shiraki K, Sobue G, Toda T, Wada K, Onodera O, Nagai Y. Arginine is a disease modifier for polyQ disease models that stabilizes polyQ protein conformation. Brain 2021; 143:1811-1825. [PMID: 32436573 DOI: 10.1093/brain/awaa115] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 01/12/2020] [Accepted: 02/23/2020] [Indexed: 12/15/2022] Open
Abstract
The polyglutamine (polyQ) diseases are a group of inherited neurodegenerative diseases that include Huntington's disease, various spinocerebellar ataxias, spinal and bulbar muscular atrophy, and dentatorubral pallidoluysian atrophy. They are caused by the abnormal expansion of a CAG repeat coding for the polyQ stretch in the causative gene of each disease. The expanded polyQ stretches trigger abnormal β-sheet conformational transition and oligomerization followed by aggregation of the polyQ proteins in the affected neurons, leading to neuronal toxicity and neurodegeneration. Disease-modifying therapies that attenuate both symptoms and molecular pathogenesis of polyQ diseases remain an unmet clinical need. Here we identified arginine, a chemical chaperone that facilitates proper protein folding, as a novel compound that targets the upstream processes of polyQ protein aggregation by stabilizing the polyQ protein conformation. We first screened representative chemical chaperones using an in vitro polyQ aggregation assay, and identified arginine as a potent polyQ aggregation inhibitor. Our in vitro and cellular assays revealed that arginine exerts its anti-aggregation property by inhibiting the toxic β-sheet conformational transition and oligomerization of polyQ proteins before the formation of insoluble aggregates. Arginine exhibited therapeutic effects on neurological symptoms and protein aggregation pathology in Caenorhabditis elegans, Drosophila, and two different mouse models of polyQ diseases. Arginine was also effective in a polyQ mouse model when administered after symptom onset. As arginine has been safely used for urea cycle defects and for mitochondrial myopathy, encephalopathy, lactic acid and stroke syndrome patients, and efficiently crosses the blood-brain barrier, a drug-repositioning approach for arginine would enable prompt clinical application as a promising disease-modifier drug for the polyQ diseases.
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Affiliation(s)
- Eiko N Minakawa
- Department of Degenerative Neurological Diseases, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Helena Akiko Popiel
- Department of Degenerative Neurological Diseases, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan.,Division of Clinical Genetics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Masayoshi Tada
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Niigata, Japan
| | - Toshiaki Takahashi
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Niigata, Japan
| | - Hiroshi Yamane
- Department of Degenerative Neurological Diseases, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Yuji Saitoh
- Department of Degenerative Neurological Diseases, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | | | - Daisaku Ozawa
- Department of Neurotherapeutics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Akiko Takeda
- Department of Neurotherapeutics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Toshihide Takeuchi
- Department of Degenerative Neurological Diseases, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan.,Department of Neurotherapeutics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yuma Okamoto
- Department of Degenerative Neurological Diseases, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan.,Division of Clinical Genetics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kazuhiro Yamamoto
- Department of Degenerative Neurological Diseases, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Mari Suzuki
- Department of Degenerative Neurological Diseases, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan.,Department of Neurotherapeutics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hiromi Fujita
- Department of Degenerative Neurological Diseases, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Chiyomi Ito
- Division of Clinical Genetics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hiroko Yagihara
- Department of Degenerative Neurological Diseases, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Yuko Saito
- Department of Pathology and Laboratory Medicine, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Kei Watase
- Center for Brain Integration Research, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Hiroaki Adachi
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kentaro Shiraki
- Faculty of Pure and Applied Sciences, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Gen Sobue
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Tatsushi Toda
- Division of Clinical Genetics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Keiji Wada
- Department of Degenerative Neurological Diseases, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Osamu Onodera
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Niigata, Japan
| | - Yoshitaka Nagai
- Department of Degenerative Neurological Diseases, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan.,Division of Clinical Genetics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.,Department of Neurotherapeutics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.,Department of Neurology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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13
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Abstract
Epilepsy is frequently a severe and sinister symptom in primary mitochondrial diseases, a group of more than 350 different genetic disorders characterized by mitochondrial dysfunction and extreme clinical and biochemical heterogeneity. Mitochondrial epilepsy is notoriously difficult to manage, principally because the vast majority of primary mitochondrial diseases currently lack effective therapies. Treating the underlying mitochondrial disorder is likely to be a more effective strategy than using traditional antiepileptic drugs. This review, initially presented at the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures at the Francis Crick Institute in London, summarizes the currently available and emerging therapies for mitochondrial epilepsy. Potentially treatable mitochondrial diseases include disorders of coenzyme Q10 biosynthesis and a group of mitochondrial respiratory chain complex I subunit and assembly factor defects that respond to riboflavin (vitamin B2). Approaches that have been adopted in actively recruiting clinical trials include redox modulation, harnessing mitochondrial biogenesis, using rapamycin to target mitophagy, nucleoside supplementation, and gene and cell therapies. Most of the clinical trials are at an early stage (Phase 1 or 2) and none of the currently active trials is specifically targeting mitochondrial epilepsy. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".
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14
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Koga Y, Povalko N, Inoue E, Nakamura H, Ishii A, Suzuki Y, Yoneda M, Kanda F, Kubota M, Okada H, Fujii K. Therapeutic regimen of L-arginine for MELAS: 9-year, prospective, multicenter, clinical research. J Neurol 2018; 265:2861-2874. [PMID: 30269300 PMCID: PMC6244654 DOI: 10.1007/s00415-018-9057-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/07/2018] [Accepted: 09/08/2018] [Indexed: 12/26/2022]
Abstract
Objective To examine the efficacy and safety of the therapeutic regimen using oral and intravenous l-arginine for pediatric and adult patients with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS). Methods In the presence and absence of an ictus of stroke-like episodes within 6 h prior to efficacy assessment, we correspondingly conducted the systematic administration of oral and intravenous l-arginine to 15 and 10 patients with MELAS in two, 2-year, prospective, multicenter clinical trials at 10 medical institutions in Japan. Subsequently, patients were followed up for 7 years. The primary endpoint in the clinical trial of oral l-arginine was the MELAS scale, while that for intravenous l-arginine was the improvement rates of headache and nausea/vomiting at 2 h after completion of the initial intravenous administration. The relationships between the ictuses of stroke-like episodes and plasma arginine concentrations were examined. Results Oral l-arginine extended the interictal phase (p = 0.0625) and decreased the incidence and severity of ictuses. Intravenous l-arginine improved the rates of four major symptoms—headache, nausea/vomiting, impaired consciousness, and visual disturbance. The maximal plasma arginine concentration was 167 μmol/L when an ictus developed. Neither death nor bedriddenness occurred during the 2-year clinical trials, and the latter did not develop during the 7-year follow-up despite the progressively neurodegenerative and eventually life-threatening nature of MELAS. No treatment-related adverse events occurred, and the formulations of l-arginine were well tolerated. Conclusions The systematic administration of oral and intravenous l-arginine may be therapeutically beneficial and clinically useful for patients with MELAS.
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Affiliation(s)
- Yasutoshi Koga
- Department of Pediatrics and Child Health, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0001, Japan.
| | - Nataliya Povalko
- Department of Pediatrics and Child Health, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0001, Japan.,Institute of Fundamental Medicine and Biology, Open Lab Gene and Cell Technology, Kazan Federal University, Kazan, Russia
| | - Eisuke Inoue
- Division of Medical Informatics, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hidefumi Nakamura
- Center for Clinical Research and Development, National Center for Child Health and Development, Setagaya, Japan
| | - Akiko Ishii
- Department of Neurology, Tsukuba University School of Medicine, Tsukuba, Japan
| | - Yasuhiro Suzuki
- Department of Pediatric Neurology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Makoto Yoneda
- Department of Neurology, Faculty of Nursing and Social Welfare Sciences, Fukui Prefectural University, Fukui, Japan
| | - Fumio Kanda
- Department of Neurology, Kobe University Hospital, Kobe, Japan
| | - Masaya Kubota
- Division of Neurology, National Center for Child Health and Development, Setagaya, Japan
| | - Hisashi Okada
- Department of Neurology, Nagoya Medical Center, Nagoya, Japan
| | - Katsunori Fujii
- Department of Pediatrics, Chiba University Graduate School of Medicine, Chiba, Japan
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15
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Sakai S, Osaki M, Hidaka M, Kimura S, Ohya Y, Ago T, Kitazono T, Arakawa S. Association between stroke-like episodes and neuronal hyperexcitability in MELAS with m.3243A>G: A case report. eNeurologicalSci 2018; 12:39-41. [PMID: 30229135 PMCID: PMC6141306 DOI: 10.1016/j.ensci.2018.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 08/20/2018] [Indexed: 01/09/2023] Open
Abstract
The pathophysiology of the stroke-like episodes of MELAS has not completely been elucidated. Here we report a case of stroke-like episodes, successfully treated with levetiracetam. Neuronal hyperexcitability can be the underlying mechanism of stroke-like episodes in MELAS.
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Affiliation(s)
- Shota Sakai
- Department of Cerebrovascular Medicine, Steel Memorial Yawata Hospital, 1-1-1 Harunomachi, Yahatahigashi-ku, Kitakyushu, Fukuoka 805-0050, Japan
| | - Masato Osaki
- Department of Cerebrovascular Medicine, Steel Memorial Yawata Hospital, 1-1-1 Harunomachi, Yahatahigashi-ku, Kitakyushu, Fukuoka 805-0050, Japan
| | - Masaoki Hidaka
- Department of Cerebrovascular Medicine, Steel Memorial Yawata Hospital, 1-1-1 Harunomachi, Yahatahigashi-ku, Kitakyushu, Fukuoka 805-0050, Japan
| | - Shunsuke Kimura
- Department of Cerebrovascular Medicine, Steel Memorial Yawata Hospital, 1-1-1 Harunomachi, Yahatahigashi-ku, Kitakyushu, Fukuoka 805-0050, Japan
| | - Yuichiro Ohya
- Department of Cerebrovascular Medicine, Steel Memorial Yawata Hospital, 1-1-1 Harunomachi, Yahatahigashi-ku, Kitakyushu, Fukuoka 805-0050, Japan
| | - Tetsuro Ago
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, Fukuoka 812-8582, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, Fukuoka 812-8582, Japan
| | - Shuji Arakawa
- Department of Cerebrovascular Medicine, Steel Memorial Yawata Hospital, 1-1-1 Harunomachi, Yahatahigashi-ku, Kitakyushu, Fukuoka 805-0050, Japan
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Lehmann D, McFarland R. Overview of Approaches to Mitochondrial Disease Therapy. JOURNAL OF INBORN ERRORS OF METABOLISM AND SCREENING 2018. [DOI: 10.1177/2326409817752960] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Diana Lehmann
- Wellcome Centre for Mitochondrial Research, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
- Department of Neurology, University of Halle-Wittenberg, Halle/Saale, Germany
| | - Robert McFarland
- Wellcome Centre for Mitochondrial Research, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
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17
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Frey S, Geffroy G, Desquiret-Dumas V, Gueguen N, Bris C, Belal S, Amati-Bonneau P, Chevrollier A, Barth M, Henrion D, Lenaers G, Bonneau D, Reynier P, Procaccio V. The addition of ketone bodies alleviates mitochondrial dysfunction by restoring complex I assembly in a MELAS cellular model. Biochim Biophys Acta Mol Basis Dis 2016; 1863:284-291. [PMID: 27815040 DOI: 10.1016/j.bbadis.2016.10.028] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 10/24/2016] [Accepted: 10/29/2016] [Indexed: 02/07/2023]
Abstract
Ketogenic Diet used to treat refractory epilepsy for almost a century may represent a treatment option for mitochondrial disorders for which effective treatments are still lacking. Mitochondrial complex I deficiencies are involved in a broad spectrum of inherited diseases including Mitochondrial Encephalomyopathy, Lactic Acidosis and Stroke-like episodes syndrome leading to recurrent cerebral insults resembling strokes and associated with a severe complex I deficiency caused by mitochondrial DNA (mtDNA) mutations. The analysis of MELAS neuronal cybrid cells carrying the almost homoplasmic m.3243A>G mutation revealed a metabolic switch towards glycolysis with the production of lactic acid, severe defects in respiratory chain activity and complex I disassembly with an accumulation of assembly intermediates. Metabolites, NADH/NAD+ ratio, mitochondrial enzyme activities, oxygen consumption and BN-PAGE analysis were evaluated in mutant compared to control cells. A severe complex I enzymatic deficiency was identified associated with a major complex I disassembly with an accumulation of assembly intermediates of 400kDa. We showed that Ketone Bodies (KB) exposure for 4weeks associated with glucose deprivation significantly restored complex I stability and activity, increased ATP synthesis and reduced the NADH/NAD+ ratio, a key component of mitochondrial metabolism. In addition, without changing the mutant load, mtDNA copy number was significantly increased with KB, indicating that the absolute amount of wild type mtDNA copy number was higher in treated mutant cells. Therefore KB may constitute an alternative and promising therapy for MELAS syndrome, and could be beneficial for other mitochondrial diseases caused by complex I deficiency.
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Affiliation(s)
- Samuel Frey
- UMR CNRS 6214-INSERM U1083, Mitovasc Institute, Angers University, Angers, France
| | - Guillaume Geffroy
- UMR CNRS 6214-INSERM U1083, Mitovasc Institute, Angers University, Angers, France
| | - Valerie Desquiret-Dumas
- UMR CNRS 6214-INSERM U1083, Mitovasc Institute, Angers University, Angers, France; Biochemistry and Genetics Department, Angers Hospital, F-49000, France
| | - Naig Gueguen
- UMR CNRS 6214-INSERM U1083, Mitovasc Institute, Angers University, Angers, France; Biochemistry and Genetics Department, Angers Hospital, F-49000, France
| | - Celine Bris
- UMR CNRS 6214-INSERM U1083, Mitovasc Institute, Angers University, Angers, France; Biochemistry and Genetics Department, Angers Hospital, F-49000, France
| | - Sophie Belal
- UMR CNRS 6214-INSERM U1083, Mitovasc Institute, Angers University, Angers, France
| | - Patrizia Amati-Bonneau
- UMR CNRS 6214-INSERM U1083, Mitovasc Institute, Angers University, Angers, France; Biochemistry and Genetics Department, Angers Hospital, F-49000, France
| | - Arnaud Chevrollier
- UMR CNRS 6214-INSERM U1083, Mitovasc Institute, Angers University, Angers, France
| | - Magalie Barth
- Biochemistry and Genetics Department, Angers Hospital, F-49000, France
| | - Daniel Henrion
- UMR CNRS 6214-INSERM U1083, Mitovasc Institute, Angers University, Angers, France
| | - Guy Lenaers
- UMR CNRS 6214-INSERM U1083, Mitovasc Institute, Angers University, Angers, France
| | - Dominique Bonneau
- UMR CNRS 6214-INSERM U1083, Mitovasc Institute, Angers University, Angers, France; Biochemistry and Genetics Department, Angers Hospital, F-49000, France
| | - Pascal Reynier
- UMR CNRS 6214-INSERM U1083, Mitovasc Institute, Angers University, Angers, France; Biochemistry and Genetics Department, Angers Hospital, F-49000, France
| | - Vincent Procaccio
- UMR CNRS 6214-INSERM U1083, Mitovasc Institute, Angers University, Angers, France; Biochemistry and Genetics Department, Angers Hospital, F-49000, France.
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18
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Lax NZ, Gorman GS, Turnbull DM. Review: Central nervous system involvement in mitochondrial disease. Neuropathol Appl Neurobiol 2016; 43:102-118. [PMID: 27287935 PMCID: PMC5363248 DOI: 10.1111/nan.12333] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 06/03/2016] [Accepted: 06/11/2016] [Indexed: 12/13/2022]
Abstract
Mitochondrial respiratory chain defects are an important cause of inherited disorders affecting approximately 1 in 5000 people in the UK population. Collectively these disorders are termed ‘mitochondrial diseases’ and they result from either mitochondrial DNA mutations or defects in nuclear DNA. Although they are frequently multisystem disorders, neurological deficits are particularly common, wide‐ranging and disabling for patients. This review details the manifold neurological impairments associated with mitochondrial disease, and describes the efforts to understand how they arise and progressively worsen in patients with mitochondrial disease. We describe advances in our understanding of disease pathogenesis through detailed neuropathological studies and how this has spurred the development of cellular and animal models of disease. We underscore the importance of continued clinical, molecular genetic, neuropathological and animal model studies to fully characterize mitochondrial diseases and understand mechanisms of neurodegeneration. These studies are instrumental for the next phase of mitochondrial research that has a particular emphasis on finding novel ways to treat mitochondrial disease to improve patient care and quality of life.
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Affiliation(s)
- N Z Lax
- The Wellcome Trust Centre for Mitochondrial Research, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - G S Gorman
- The Wellcome Trust Centre for Mitochondrial Research, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - D M Turnbull
- The Wellcome Trust Centre for Mitochondrial Research, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
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19
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Abstract
BACKGROUND the maternally inherited MTTL1 A3243G mutation in the mitochondrial genome causes MelaS (Mitochondrial encephalopathy lactic acidosis with Stroke-like episodes), a condition that is multisystemic but affects primarily the nervous system. Significant intra-familial variation in phenotype and severity of disease is well recognized. METHODS retrospective and ongoing study of an extended family carrying the MTTL1 A3243G mutation with multiple symptomatic individuals. tissue heteroplasmy is reviewed based on the clinical presentations, imaging studies, laboratory findings in affected individuals and pathological material obtained at autopsy in two of the family members. RESULTS there were seven affected individuals out of thirteen members in this three generation family who each carried the MTTL1 A3243G mutation. the clinical presentations were varied with symptoms ranging from hearing loss, migraines, dementia, seizures, diabetes, visual manifestations, and stroke like episodes. three of the family members are deceased from MelaS or to complications related to MelaS. CONCLUSIONS the results of the clinical, pathological and radiological findings in this family provide strong support to the current concepts of maternal inheritance, tissue heteroplasmy and molecular pathogenesis in MelaS. neurologists (both adult and paediatric) are the most likely to encounter patients with MelaS in their practice. genetic counselling is complex in view of maternal inheritance and heteroplasmy. newer therapeutic options such as arginine are being used for acute and preventative management of stroke like episodes.
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20
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Fryer RH, Bain J, De Vivo D. Mitochondrial Encephalomyopathy Lactic Acidosis and Stroke-Like Episodes (MELAS): A Case Report and Critical Reappraisal of Treatment Options. Pediatr Neurol 2016; 56:59-61. [PMID: 26797286 PMCID: PMC4789111 DOI: 10.1016/j.pediatrneurol.2015.12.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 12/15/2015] [Indexed: 01/31/2023]
Abstract
IMPORTANCE Stroke-like episodes signal progression and significant disability in the mitochondrial encephalomyopathy lactic acidosis and stroke-like episodes syndrome. Arginine is widely used as a treatment for stroke-like episode, although there is little evidence for this intervention. We discuss the management of a patient with mitochondrial encephalomyopathy lactic acidosis and stroke-like episodes who presented with a stroke-like episode. OBSERVATION During a seizure, which triggers the stroke-like episode, neurons are forced to utilize glycolysis as a source of adenosine triphosphate. Glycolytic by-products are damaging to the neuron. Breakdown of the blood-brain barrier leads to vasogenic edema. CONCLUSION Treatment of stroke-like episode should include anticonvulsants interictally to prevent seizures and dexamethasone ictally to help repair the blood-brain barrier.
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Affiliation(s)
- Robert H. Fryer
- Department of Neurology, Columbia University Medical Center, New York, NY,Corresponding Author: Robert H. Fryer, MD, PHD, 180 Fort Washington Avenue, Harkness 5th floor, New York, NY 10032, 212-342-2919 (P), 212-342-6865 (F),
| | - Jennifer Bain
- Department of Neurology, Columbia University Medical Center, New York, NY
| | - Darryl De Vivo
- Department of Neurology, Columbia University Medical Center, New York, NY
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21
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Khan NA, Govindaraj P, Meena AK, Thangaraj K. Mitochondrial disorders: challenges in diagnosis & treatment. Indian J Med Res 2016; 141:13-26. [PMID: 25857492 PMCID: PMC4405934 DOI: 10.4103/0971-5916.154489] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Mitochondrial dysfunctions are known to be responsible for a number of heterogenous clinical presentations with multi-systemic involvement. Impaired oxidative phosphorylation leading to a decrease in cellular energy (ATP) production is the most important cause underlying these disorders. Despite significant progress made in the field of mitochondrial medicine during the last two decades, the molecular mechanisms underlying these disorders are not fully understood. Since the identification of first mitochondrial DNA (mtDNA) mutation in 1988, there has been an exponential rise in the identification of mtDNA and nuclear DNA mutations that are responsible for mitochondrial dysfunction and disease. Genetic complexity together with ever widening clinical spectrum associated with mitochondrial dysfunction poses a major challenge in diagnosis and treatment. Effective therapy has remained elusive till date and is mostly efficient in relieving symptoms. In this review, we discuss the important clinical and genetic features of mitochondrials disorders with special emphasis on diagnosis and treatment.
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Affiliation(s)
| | | | | | - Kumarasamy Thangaraj
- CSIR-Centre for Cellular & Molecular Biology, Nizam's Institute of Medical Sciences, Hyderabad, India
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22
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Kasner SE, Cucchiara BL. Treatment of “Other” Stroke Etiologies. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00056-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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23
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Therapeutic strategies for mitochondrial disorders. Pediatr Neurol 2015; 52:302-13. [PMID: 25701186 DOI: 10.1016/j.pediatrneurol.2014.06.023] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 06/14/2014] [Accepted: 06/19/2014] [Indexed: 12/31/2022]
Abstract
OBJECTIVES There is currently no curative therapy for mitochondrial disorders, although symptomatic measures can be highly effective and greatly improve the quality of life and outcome of these patients. This review highlights potential strategies for the therapeutic management of mitochondrial disorders. METHODS Data for this review were identified by searches of MEDLINE, Current Contents, using various relevant search terms. RESULTS Strategies to establish a therapeutic regimen aim to enhance respiratory chain function, eliminate noxious compounds, shift the heteroplasmy rate, alter mitochondrial dynamics, transfer cytoplasm, and promote gene therapy. Symptomatic measures rely on drugs (e.g., antiepileptics), avoidance of mitochondrion-toxic agents, substitution of blood cells, hemodialysis, invasive measures (such as a pacemaker), surgery (e.g., ptosis correction), physiotherapy, speech therapy, occupational therapy, dietary measures (e.g., ketogenic diet, anaplerotic diet), and the avoidance of mitochondrion-toxic agents (e.g., ozone). With the increasing awareness of mitochondrial disorders, the number of treatment studies is growing and its quality is improving. If high quality studies (high Jadad score) yield statistical significance for end points, a treatment is more reliable than with lower quality studies. CONCLUSIONS Despite the lack of a proven treatment for mitochondrial disorders, a nihilistic attitude toward treatment is not justified. A number of studies are seeking targeted therapies, and highly effective symptomatic measures are available.
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Demarest ST, Whitehead MT, Turnacioglu S, Pearl PL, Gropman AL. Phenotypic analysis of epilepsy in the mitochondrial encephalomyopathy, lactic acidosis, and strokelike episodes-associated mitochondrial DNA A3243G mutation. J Child Neurol 2014; 29:1249-56. [PMID: 25038129 DOI: 10.1177/0883073814538511] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The A to G mitochondrial DNA point mutation at position 3243 (A3243G) is the most common cause of mitochondrial encephalomyopathy, lactic acidosis, and strokelike episodes (MELAS), a systemic multiorgan disease. Epilepsy is a common finding but there is wide phenotypic variation that has not been thoroughly explored. We report the epilepsy phenotypes of 7 patients with the A3243G mutation. Most presented with typical MELAS and epilepsy characterized by infrequent prolonged focal seizures, including epilepsia partialis continua, hemiclonic status epilepticus, nonconvulsive status, and occipital status epilepticus. Seizures usually occurred during the acute phase of a strokelike episode. Periodic lateralized epileptiform discharges may be seen electrographically. Some patients with this mutation are completely asymptomatic or have mild symptoms typical for mitochondrial diseases. Slow spike-wave activity consistent with Lennox-Gastaut syndrome and electrographic status epilepticus was seen in 1 patient who responded to ethosuximide.
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Affiliation(s)
- Scott T Demarest
- Children's National Medical Center, The George Washington University School of Medicine, Washington, DC, USA
| | - Matthew T Whitehead
- Children's National Medical Center, The George Washington University School of Medicine, Washington, DC, USA
| | - Sinan Turnacioglu
- Children's National Medical Center, The George Washington University School of Medicine, Washington, DC, USA
| | - Phillip L Pearl
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrea L Gropman
- Children's National Medical Center, The George Washington University School of Medicine, Washington, DC, USA
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25
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Avula S, Parikh S, Demarest S, Kurz J, Gropman A. Treatment of mitochondrial disorders. Curr Treat Options Neurol 2014; 16:292. [PMID: 24700433 DOI: 10.1007/s11940-014-0292-7] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OPINION STATEMENT While numerous treatments for mitochondrial disorders have been suggested, relatively few have undergone controlled clinical trials. Treatment of these disorders is challenging, as only symptomatic therapy is available. In this review we will focus on newer drugs and treatment trials in mitochondrial diseases, with a special focus on medications to avoid in treating epilepsy and ICU patient with mitochondrial disease, which has not been included in such a review. Readers are also referred to the opinion statement in A Modern Approach to the Treatment of Mitochondrial Disease published in Current Treatment Options in Neurology 2009. Many of the supplements used for treatment were reviewed in the previous abstract, and dosing guidelines were provided. The focus of this review is on items not previously covered in depth, and our discussion includes more recently studied compounds as well as any relevant updates on older compounds . We review a variety of vitamins and xenobiotics, including dichloroacetate (DCA), arginine, coenzyme Q10, idebenone, EPI-743, and exercise training. Treatment of epilepsy, which is a common feature in many mitochondrial phenotypes, warrants special consideration due to the added toxicity of certain medications, and we provide a discussion of these unique treatment challenges. Interesting, however, with only a few exceptions, the treatment strategies for epilepsy in mitochondrial cytopathies are the same as for epilepsy without mitochondrial dysfunction. We also discuss intensive care management, building upon similar reviews, adding new dimensions, and demonstrating the complexity of overall care of these patients.
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Affiliation(s)
- Sreenivas Avula
- Department of Neurology, Cleveland Clinic, Cleveland, OH, USA,
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26
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Tsujikawa K, Yokoi S, Yasui K, Hasegawa Y, Hoshiyama M, Yanagi T. [Effectiveness of midazolam for L-arginine-resistant headaches during stroke-like episodes in MELAS: a case report]. Rinsho Shinkeigaku 2014; 54:882-887. [PMID: 25420561 DOI: 10.5692/clinicalneurol.54.882] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
A 14-year-old girl was referred to us with severe migraine-like headaches associated with vomiting and right homonymous hemianopsia. On admission, MRI examination showed high signals in the left occipital cortex and subcortex on T2-weighted images, without reduction of apparent diffusion coefficient suggestive of cerebral infarction. Her EEG demonstrated periodic sharp waves in the left posterior region, and laboratory tests revealed she had increased levels of lactic and pyruvic acid both in blood plasma and CSF. Gene analysis confirmed mitochondrial DNA A3243G mutation. Based on this data, we diagnosed her as having mitochondrial myopathy, encephalopathy, lactic acidosis and a stroke-like episode (MELAS). L-arginine infusion was unsuccessful for her severe headaches, which remained prolonged. She received a low dose (0.05 mg/kg/h) midazolam infusion, resulting in immediate improvement and the disappearance of headaches and abnormal EEG findings. By the age of 18, she had been readmitted eight times for stroke-like episodes accompanied by headaches. While L-arginine infusions alleviated her headaches when administered on day 1 of her episodes, they were not effective when started on or after day 2. Her L-arginine-resistant headaches were relieved by midazolam. Although the pathogenesis of headaches in MELAS is still unknown, neuronal hyperexcitability and trigeminovascular activation are considered important. Midazolam may play a role in suppressing neuronal hyperexcitability and trigeminovascular activation. Treatment with midazolam is advisable for headaches in patients with MELAS, in the event that L-arginine therapy is unsuccessful.
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Affiliation(s)
- Koyo Tsujikawa
- Department of Neurology, Nagoya Daini Red Cross Hospital
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27
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Pfeffer G, Horvath R, Klopstock T, Mootha VK, Suomalainen A, Koene S, Hirano M, Zeviani M, Bindoff LA, Yu-Wai-Man P, Hanna M, Carelli V, McFarland R, Majamaa K, Turnbull DM, Smeitink J, Chinnery PF. New treatments for mitochondrial disease-no time to drop our standards. Nat Rev Neurol 2013; 9:474-81. [PMID: 23817350 PMCID: PMC4967498 DOI: 10.1038/nrneurol.2013.129] [Citation(s) in RCA: 123] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Mitochondrial dysfunction is a common cause of inherited multisystem disease that often involves the nervous system. Despite major advances in our understanding of the pathophysiology of mitochondrial diseases, clinical management of these conditions remains largely supportive. Using a systematic approach, we identified 1,039 publications on treatments for mitochondrial diseases, only 35 of which included observations on more than five patients. Reports of a positive outcome on the basis of a biomarker of unproven clinical significance were more common in nonrandomized and nonblinded studies, suggesting a publication bias toward positive but poorly executed studies. Although trial design is improving, there is a critical need to develop new biomarkers of mitochondrial disease. In this Perspectives article, we make recommendations for the design of future treatment trials in mitochondrial diseases. Patients and physicians should no longer rely on potentially biased data, with the associated costs and risks.
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Affiliation(s)
- Gerald Pfeffer
- Wellcome Trust Centre for Mitochondrial Research, Institute of Genetic Medicine, Ageing and Health, Newcastle University, Newcastle upon Tyne NE1 3BZ, UK
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28
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Effects of L-arginine on anatomical and electrophysiological deterioration of the eye in a rodent model of nonarteritic ischemic optic neuropathy. Jpn J Ophthalmol 2013; 57:402-9. [PMID: 23712653 DOI: 10.1007/s10384-013-0250-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 04/08/2013] [Indexed: 02/05/2023]
Abstract
PURPOSE The aims of this study were to clarify the effectiveness of L-arginine (1) for reducing the severity of anatomical changes in the eye and improving visual function in the acute stage of a rodent model of nonarteritic ischemic optic neuropathy (rNAION) and (2) in preventing those changes in anatomy and visual function. METHODS For the first aim, L-arginine was intravenously injected into rats 3 h after rNAION induction; for the second aim, rNAION was induced after the oral administration of L-arginine for 7 days. The inner retinal thickness was determined over time by optical coherence tomography, and the amplitude of the scotopic threshold response (STR) and the number of surviving retinal ganglion cells (RGCs) were measured. These data were compared with the baseline data from the control group. RESULTS Both intravenous infusion of L-arginine after rNAION induction and oral pretreatment with L-arginine significantly decreased optic disc edema in the acute stage and thinning of the inner retina, reduced the decrease in STR amplitude, and reduced the decrease in the number of RGCs during rNAION. CONCLUSION Based on these results, we conclude that L-arginine treatment is effective for reducing anatomical changes in the eye and improving visual function in the acute stage of rNAION and that pretreatment with L-arginine is an effective therapy to reduce the severity of the condition during recurrence in the other eye.
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Yeh HL, Chen YK, Chen WH, Wang HC, Chiu HC, Lien LM, Wei YH. Perfusion status of the stroke-like lesion at the hyperacute stage in MELAS. Brain Dev 2013; 35:158-64. [PMID: 22516515 DOI: 10.1016/j.braindev.2012.03.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Revised: 03/27/2012] [Accepted: 03/28/2012] [Indexed: 11/28/2022]
Abstract
Hypoperfusion on single-photon emission computed tomography (SPECT) of the stroke-like lesion (SLL) at the hyperacute stage of mitochondrial encephalopathy with lactic acidosis and stroke-like episodes (MELAS) is considered to be a supportive evidence of the mitochondrial angiopathy theory. Our objectives were to examine whether other neuroimages, especially transcranial color-coded sonography (TCCS), done at the hyperacute stage of stroke-like episode (SLE) is consistent with hypoperfusion of the SLL. We reviewed the magnetic resonance imaging (MRI), SPECT, cerebral angiography, and TCCS of a patient with MELAS syndrome, all of which were performed at the hyperacute stage of one SLE. MRI on the 1st day post SLE showed right temporoparietal lesion with vasogenic edema. SPECT on the 2nd day showed focal decreased uptake of technetium-99m hexamethylpropyleneamine oxime ((99m)Tc-HMPAO) in the same region, but cerebral angiography and TCCS on the 3rd day showed increased regional cerebral blood flow (rCBF) and distal arteriole dilation in the same region. TCCS can delineate increased rCBF of the SLL at the hyperacute stage of SLE. We propose that the discrepancy between the decreased (99m)Tc-HMPAO uptake and increased rCBF might be caused by mitochondrial dysfunction. The phenomenon of "hypoperfusion" on SPECT might be caused by cell dysfunction but not decreased rCBF. We suggest that SPECT can be complemented by angiography and TCCS in future studies to delineate the perfusion status of SLLs.
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Affiliation(s)
- Hsu-Ling Yeh
- Department of Neurology, Shin-Kong WHS Memorial Hospital, No. 95 Wenchang Road, Taipei, Taiwan
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Gamba J, Gamba LT, Rodrigues GS, Kiyomoto BH, Moraes CT, Tengan CH. Nitric oxide synthesis is increased in cybrid cells with m.3243A>G mutation. Int J Mol Sci 2012; 14:394-410. [PMID: 23263669 PMCID: PMC3565270 DOI: 10.3390/ijms14010394] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Revised: 12/10/2012] [Accepted: 12/14/2012] [Indexed: 12/16/2022] Open
Abstract
Nitric oxide (NO) is a free radical and a signaling molecule in several pathways, produced by nitric oxide synthase (NOS) from the conversion of l-arginine to citrulline. Supplementation of l-arginine has been used to treat MELAS (mitochondrial encephalopathy with lactic acidosis and stroke like syndrome), a mitochondrial disease caused by the m.3243A>G mutation. Low levels of serum arginine and endothelium dysfunction have been reported in MELAS and this treatment may increase NO in endothelial cells and promote vasodilation, decreasing cerebral ischemia and strokes. Although clinical benefits have been reported, little is known about NO synthesis in MELAS. In this study we found that osteosarcoma derived cybrid cells with high levels of m.3243A>G had increased nitrite, an NO metabolite, and increased intracellular NO, demonstrated by an NO fluorescent probe (DAF-FM). Muscle vessels from patients with the same mutation had increased staining in NADPH diaphorase, suggestive of increased NOS. These results indicate increased production of NO in cells harboring the m.3243A>G, however no nitrated protein was detected by Western blotting. Further studies are necessary to clarify the exact mechanisms of l-arginine effect to determine the appropriate clinical use of this drug therapy.
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Affiliation(s)
- Juliana Gamba
- Department of Neurology and Neurosurgery, Escola Paulista de Medicina, Universidade Federal de São Paulo, R. Pedro de Toledo, 781, São Paulo 04039-032, Brazil; E-Mails: (J.G.); (L.T.G.); (G.S.R.); (B.H.K.)
| | - Luana T. Gamba
- Department of Neurology and Neurosurgery, Escola Paulista de Medicina, Universidade Federal de São Paulo, R. Pedro de Toledo, 781, São Paulo 04039-032, Brazil; E-Mails: (J.G.); (L.T.G.); (G.S.R.); (B.H.K.)
| | - Gabriela S. Rodrigues
- Department of Neurology and Neurosurgery, Escola Paulista de Medicina, Universidade Federal de São Paulo, R. Pedro de Toledo, 781, São Paulo 04039-032, Brazil; E-Mails: (J.G.); (L.T.G.); (G.S.R.); (B.H.K.)
| | - Beatriz H. Kiyomoto
- Department of Neurology and Neurosurgery, Escola Paulista de Medicina, Universidade Federal de São Paulo, R. Pedro de Toledo, 781, São Paulo 04039-032, Brazil; E-Mails: (J.G.); (L.T.G.); (G.S.R.); (B.H.K.)
| | - Carlos T. Moraes
- Department of Neurology and Cell Biology, Miller School of Medicine, University of Miami, Miami, FL 33101, USA; E-Mail:
| | - Celia H. Tengan
- Department of Neurology and Neurosurgery, Escola Paulista de Medicina, Universidade Federal de São Paulo, R. Pedro de Toledo, 781, São Paulo 04039-032, Brazil; E-Mails: (J.G.); (L.T.G.); (G.S.R.); (B.H.K.)
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +55-11-5576-4465; Fax: +55-11-5085-5000
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Nitric oxide in skeletal muscle: role on mitochondrial biogenesis and function. Int J Mol Sci 2012; 13:17160-84. [PMID: 23242154 PMCID: PMC3546744 DOI: 10.3390/ijms131217160] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Revised: 12/04/2012] [Accepted: 12/05/2012] [Indexed: 01/18/2023] Open
Abstract
Nitric oxide (NO) has been implicated in several cellular processes as a signaling molecule and also as a source of reactive nitrogen species (RNS). NO is produced by three isoenzymes called nitric oxide synthases (NOS), all present in skeletal muscle. While neuronal NOS (nNOS) and endothelial NOS (eNOS) are isoforms constitutively expressed, inducible NOS (iNOS) is mainly expressed during inflammatory responses. Recent studies have demonstrated that NO is also involved in the mitochondrial biogenesis pathway, having PGC-1α as the main signaling molecule. Increased NO synthesis has been demonstrated in the sarcolemma of skeletal muscle fiber and NO can also reversibly inhibit cytochrome c oxidase (Complex IV of the respiratory chain). Investigation on cultured skeletal myotubes treated with NO donors, NO precursors or NOS inhibitors have also showed a bimodal effect of NO that depends on the concentration used. The present review will discuss the new insights on NO roles on mitochondrial biogenesis and function in skeletal muscle. We will also focus on potential therapeutic strategies based on NO precursors or analogs to treat patients with myopathies and mitochondrial deficiency.
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Koga Y, Povalko N, Nishioka J, Katayama K, Yatsuga S, Matsuishi T. Molecular pathology of MELAS and l-arginine effects. Biochim Biophys Acta Gen Subj 2012; 1820:608-14. [DOI: 10.1016/j.bbagen.2011.09.005] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Revised: 07/07/2011] [Accepted: 09/07/2011] [Indexed: 11/30/2022]
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Abstract
Arginine hydrochloride is used in the evaluation of short stature and in the management of urea cycle disorders. In recent times, it has been used in the treatment of stroke-like episodes of MELAS (mitochondrial encephalomyopathy, lactic acidosis, stroke-like episodes). We want to highlight the need for good intravenous access and monitoring the drip site to prevent extravasation injuries that can be caused by arginine, which is a hyperosmolar solution.
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Affiliation(s)
- Mary B Abraham
- Department of Paediatrics, Hervey Bay Hospital, Queensland, Australia.
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Parikh S, Saneto R, Falk MJ, Anselm I, Cohen BH, Haas R, Medicine Society TM. A modern approach to the treatment of mitochondrial disease. Curr Treat Options Neurol 2011; 11:414-30. [PMID: 19891905 DOI: 10.1007/s11940-009-0046-0] [Citation(s) in RCA: 230] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The treatment of mitochondrial disease varies considerably. Most experts use a combination of vitamins, optimize patients' nutrition and general health, and prevent worsening of symptoms during times of illness and physiologic stress. We agree with this approach, and we agree that therapies using vitamins and cofactors have value, though there is debate about the choice of these agents and the doses prescribed. Despite the paucity of high-quality scientific evidence, these therapies are relatively harmless, may alleviate select clinical symptoms, and theoretically may offer a means of staving off disease progression. Like many other mitochondrial medicine physicians, we have observed significant (and at times life-altering) clinical responses to such pharmacologic interventions. However, it is not yet proven that these therapies truly alter the course of the disease, and some experts may choose not to use these medications at all. At present, the evidence of their effectiveness does not rise to the level required for universal use. Based on our clinical experience and judgment, however, we agree that a therapeutic trial of coenzyme Q10, along with other antioxidants, should be attempted. Although individual specialists differ as to the exact drug cocktail, a common approach involves combinations of antioxidants that may have a synergistic effect. Because almost all relevant therapies are classified as medical foods or over-the-counter supplements, most physicians also attempt to balance the apparent clinical benefit of mitochondrial cocktails with the cost burden that these supplements pose for the family.
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Affiliation(s)
- Sumit Parikh
- Sumit Parikh, MD Neurometabolism & Neurogenetics, Cleveland Clinic, 9500 Euclid Avenue, S71, Cleveland, OH 44195, USA.
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Brinjikji W, Swanson JW, Zabel C, Dyck PJ, Tracy JA, Gavrilova RH. Stroke and Stroke-Like Symptoms in Patients with Mutations in the POLG1 Gene. JIMD Rep 2011; 1:89-96. [PMID: 23430834 DOI: 10.1007/8904_2011_22] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2010] [Revised: 01/31/2011] [Accepted: 02/01/2011] [Indexed: 03/29/2023] Open
Abstract
Introduction/Methods Mutations in POLG1, the gene encoding mitochondrial polymerase gamma (Polγ), have been associated with a number of well-characterized phenotypes. In this study, we report two cases of patients with biallelic POLG1 mutations and stroke. We also performed a review of the literature and report on all clinical studies of patients with POLG1 mutations in which stroke was described in the phenotype. For each patient, genotype and phenotype are reported. Results Including our two patients, a total of 22 patients have been reported with POLG1 mutations and stroke. The average age of onset of stroke in these patients was 9 years with a range of 1-23 years. In cases where localization was reported, the occipital lobes were the primary location of the infarct. Mutations in the linker-linker or linker-polymerase domains were the most frequent genotype observed. Seizures (16/22) and hepatic dysfunction/failure (8/22) were the most commonly reported symptoms in the stroke cohort. Conclusion This article raises an underrecognized point that patients with POLG1 mutations may suffer a cerebrovascular accident at a young age. The most common location of the infarction is in the occipital lobe. The presentation may be similar to MELAS and can be misdiagnosed as a migrainous stroke.
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Shigemi R, Fukuda M, Suzuki Y, Morimoto T, Ishii E. L-arginine is effective in stroke-like episodes of MELAS associated with the G13513A mutation. Brain Dev 2011; 33:518-20. [PMID: 20832210 DOI: 10.1016/j.braindev.2010.07.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2010] [Revised: 07/05/2010] [Accepted: 07/30/2010] [Indexed: 10/19/2022]
Abstract
We report a case involving a 15-year-old boy with MELAS (G13513A mutation) who developed several stroke-like episodes in a short period of time. Intravenous administration of l-arginine during the acute phase of the stroke-like episodes reduced symptoms immediately, and oral supplementation of l-arginine successfully prevented further stroke-like episodes. This is the first report on effective l-arginine therapy in MELAS associated with the G13513A mutation.
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Affiliation(s)
- Ritsuko Shigemi
- Department of Pediatrics, Matsuyama Shimin Hospital, Ohtemachi 2-6-5, Matsuyama, Ehime 791-0067, Japan
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In vivo functional brain imaging and a therapeutic trial of L-arginine in MELAS patients. Biochim Biophys Acta Gen Subj 2011; 1820:615-8. [PMID: 21600268 DOI: 10.1016/j.bbagen.2011.04.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Revised: 04/28/2011] [Accepted: 04/29/2011] [Indexed: 11/23/2022]
Abstract
BACKGROUND Mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS) is the most common type of mitochondrial disease and is characterized by stroke-like episodes (SEs), myopathy, lactic acidosis, diabetes mellitus, hearing-loss and cardiomyopathy. The causal hypotheses for SEs in MELAS presented to date are angiopathy, cytopathy and neuronal hyperexcitability. L-arginine (Arg) has been applied for the therapy in MELAS patients. SCOPE OF REVIEW We will introduce novel in vivo functional brain imaging techniques such as MRI and PET, and discuss the pathogenesis of SEs in MELAS patients. We will further describe here our clinical experience with L-arg therapy and discuss the dual pharmaceutical effects of this drug on MELAS. MAJOR CONCLUSIONS Administration of L-arg to MELAS patients has been successful in reducing neurological symptoms due to acute strokes and preventing recurrences of SEs in the chronic phase. L-Arg has dual pharmaceutical effects on both angiopathy and cytopathy in MELAS. GENERAL SIGNIFICANCE In vivo functional brain imaging promotes a better understanding of the pathogenesis and potential therapies for MELAS patients. This article is part of a Special Issue entitled Biochemistry of Mitochondria, Life and Intervention 2010.
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Treatment of “Other” Stroke Etiologies. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10054-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Johnson ECB, West TW, Ko NU, Strober JB. A 41-year-old man with new headache and altered mental status. Neurohospitalist 2011; 1:48-54. [PMID: 23983837 PMCID: PMC3726099 DOI: 10.1177/1941875210385948] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Erik C. B. Johnson
- Department of Neurology, University of California−San Francisco, CA, USA
| | - Timothy W. West
- Department of Neurology, University of California−San Francisco, CA, USA
| | - Nerissa U. Ko
- Department of Neurology, University of California−San Francisco, CA, USA
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Finsterer J. Treatment of central nervous system manifestations in mitochondrial disorders. Eur J Neurol 2010; 18:28-38. [DOI: 10.1111/j.1468-1331.2010.03086.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Koga Y, Povalko N, Nishioka J, Katayama K, Kakimoto N, Matsuishi T. MELAS and l-arginine therapy: pathophysiology of stroke-like episodes. Ann N Y Acad Sci 2010; 1201:104-10. [DOI: 10.1111/j.1749-6632.2010.05624.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Wallace DC, Fan W, Procaccio V. Mitochondrial energetics and therapeutics. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2010; 5:297-348. [PMID: 20078222 DOI: 10.1146/annurev.pathol.4.110807.092314] [Citation(s) in RCA: 491] [Impact Index Per Article: 35.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Mitochondrial dysfunction has been linked to a wide range of degenerative and metabolic diseases, cancer, and aging. All these clinical manifestations arise from the central role of bioenergetics in cell biology. Although genetic therapies are maturing as the rules of bioenergetic genetics are clarified, metabolic therapies have been ineffectual. This failure results from our limited appreciation of the role of bioenergetics as the interface between the environment and the cell. A systems approach, which, ironically, was first successfully applied over 80 years ago with the introduction of the ketogenic diet, is required. Analysis of the many ways that a shift from carbohydrate glycolytic metabolism to fatty acid and ketone oxidative metabolism may modulate metabolism, signal transduction pathways, and the epigenome gives us an appreciation of the ketogenic diet and the potential for bioenergetic therapeutics.
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Affiliation(s)
- Douglas C Wallace
- Center for Molecular and Mitochondrial Medicine and Genetics and Departments of Biological Chemistry, Ecology and Evolutionary Biology, and Pediatrics, University of California at Irvine, Irvine, California 92697-3940, USA.
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Iizuka T, Sakai F. Pathophysiology of stroke-like episodes in MELAS: neuron–astrocyte uncoupling in neuronal hyperexcitability. FUTURE NEUROLOGY 2010. [DOI: 10.2217/fnl.09.71] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS) is a distinct clinical syndrome characterized by fluctuated encephalopathy, migraineous headache, seizure and stroke-like episodes. The molecular mechanism of MELAS mutations has been elucidated; however, the pathogenesis of stroke-like episodes remains largely unknown. Three main hypotheses include ischemic, metabolic and neuronal hyperexcitability hypotheses. Recently, emerging hypotheses include alterations in nitric oxide homeostasis and over-reduction/oxidative stress mechanisms. Although neuron–astrocyte communication is crucial in various physiological functions, it has not been seriously considered in the pathophysiology of stroke-like episodes. This review summarizes what is known about the molecular mechanisms of gene mutation, clinico-radiological, clinico-physiological and pathological features of stroke-like episodes, as well as its pathogenesis. We finally discuss potential mechanisms involved in the pathogenesis of stroke-like episodes based on currently available clinical data and the current understanding of the mechanisms of neuron–astrocyte communications. We propose that neuron–astrocyte uncoupling is a new target of research in mitochondrial disorders.
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Affiliation(s)
- Takahiro Iizuka
- Department of Neurology, School of Medicine, Kitasato University, Kanagawa, Japan
| | - Fumihiko Sakai
- International Headache Center, Shinyurigaoka, Kanagawa, Japan
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Abstract
Treatment of mitochondrial disorders (MIDs) is a challenge since there is only symptomatic therapy available and since only few randomized and controlled studies have been carried out, which demonstrate an effect of some of the symptomatic or supportive measures available. Symptomatic treatment of MIDs is based on mainstay drugs, blood transfusions, hemodialysis, invasive measures, surgery, dietary measures, and physiotherapy. Drug treatment may be classified as specific (treatment of epilepsy, headache, dementia, dystonia, extrapyramidal symptoms, Parkinson syndrome, stroke-like episodes, or non-neurological manifestations), non-specific (antioxidants, electron donors/acceptors, alternative energy sources, cofactors), or restrictive (avoidance of drugs known to be toxic for mitochondrial functions). Drugs which more frequently than in the general population cause side effects in MID patients include steroids, propofol, statins, fibrates, neuroleptics, and anti-retroviral agents. Invasive measures include implantation of a pacemaker, biventricular pacemaker, or implantable cardioverter defibrillator, or stent therapy. Dietary measures can be offered for diabetes, hyperlipidemia, or epilepsy (ketogenic diet, anaplerotic diet). Treatment should be individualized because of the peculiarities of mitochondrial genetics. Despite limited possibilities, symptomatic treatment should be offered to MID patients, since it can have a significant impact on the course and outcome.
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Hong SKS, Maltz BE, Coburn LA, Slaughter JC, Chaturvedi R, Schwartz DA, Wilson KT. Increased serum levels of L-arginine in ulcerative colitis and correlation with disease severity. Inflamm Bowel Dis 2010; 16:105-11. [PMID: 19637336 PMCID: PMC2795785 DOI: 10.1002/ibd.21035] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND L-arginine (L-Arg) is a semi-essential amino acid that is the substrate for both nitric oxide and polyamine synthesis. Cellular uptake of L-Arg is an active transport process that is subject to competitive inhibition by L-ornithine (L-Orn) and L-lysine (L-Lys). We investigated L-Arg utilization in patients with ulcerative colitis (UC). METHODS Serum was collected from 14 normal controls and 22 UC patients with pancolitis of moderate or severe activity by histopathology score. The Mayo Disease Activity Index (DAI) and endoscopy subscore were assessed. Serum amino acid levels were measured by high-performance liquid chromatography. Arginine availability index (AAI) was defined as [L-Arg]/([L-Orn] + [L-Lys]). RESULTS Serum L-Arg levels were significantly associated with histopathologic grade (P = 0.001). L-Arg levels were increased in subjects with severe colitis when compared to those with moderate colitis or normal mucosa. L-Orn + L-Lys levels were also increased in severe colitis, so that AAI was not significantly increased. L-Arg levels were also strongly associated with the endoscopy subscore (P < 0.001). There was a strong correlation between DAI and L-Arg levels (r = 0.656, P < 0.001). CONCLUSIONS Serum L-Arg levels correlate with UC disease severity but availability is not increased due to competitive inhibition by L-Orn and L-Lys. Our findings suggest that L-Arg uptake by cells in the inflamed colon is defective, which may contribute to the pathogenesis of UC. Studies delineating the mechanism of uptake inhibition could enhance our understanding of UC or lead to novel treatment options.
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Affiliation(s)
- Shih-Kuang S. Hong
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine
| | - Brad E. Maltz
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine
| | - Lori A. Coburn
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine
| | - James C. Slaughter
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rupesh Chaturvedi
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine,Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, USA
| | - David A. Schwartz
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine
| | - Keith T. Wilson
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine,Department of Cancer Biology, Vanderbilt University Medical Center, Nashville, TN, USA,Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, USA,Correspondence: Keith T. Wilson, M.D., Vanderbilt University School of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, 2215B Garland Ave., 1030C MRB IV, Nashville, TN 37232-0252, Phone 615-343-5675, Fax 615-343-6229,
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Liu GT, Volpe NJ, Galetta SL. Retrochiasmal disorders. Neuroophthalmology 2010. [DOI: 10.1016/b978-1-4160-2311-1.00008-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Finsterer J. CT und MRT des Zerebrums bei mitochondrialen Erkrankungen. DER NERVENARZT 2009; 80:700-7. [DOI: 10.1007/s00115-009-2678-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Moutaouakil F, El Otmani H, Fadel H, Sefrioui F, Slassi I. La l-arginine, une thérapeutique symptomatique efficace au cours d’un syndrome MELAS. Rev Neurol (Paris) 2009; 165:482-5. [DOI: 10.1016/j.neurol.2008.08.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2008] [Accepted: 08/21/2008] [Indexed: 10/21/2022]
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