Plasma concentration, urinary excretion and renal clearance of L-carnitine during pregnancy: a reversible secondary L-carnitine deficiency

The neural stem cell/carnitine malnutrition hypothesis: new prospects for effective reduction of autism risk?

Autism spectrum disorders (ASDs) are developmental neuropsychiatric disorders with heterogeneous etiologies. As the incidence of these disorders is rising, such disorders represent a major human health problem with escalating social cost. Although recent years witnessed advances in our understanding of the genetic basis of some dysmorphic ASDs, little progress has been made in translating the improved understanding into effective strategies for ASD management or minimization of general ASD risk. Here we explore the idea, described in terms of the neural stem cell (NSC)/carnitine malnutrition hypothesis, that an unappreciated risk factor for ASD is diminished capacity for carnitine-dependent long-chain fatty acid β-oxidation in neural stem cells of the developing mammalian brain. The basic premise is that fetal carnitine status is a significant metabolic component in determining NSC vulnerability to derangements in their self-renewal program and, therefore, to fetal ASD risk. As fetal carnitine status exhibits a genetic component that relates to de novo carnitine biosynthesis and is sensitive to environmental and behavioral factors that affect maternal circulating carnitine levels, to which the fetus is exposed, we propose that reduced carnitine availability during gestation is a common risk factor that lurks beneath the genetically complex ASD horizon. One major prediction of the NSC/carnitine malnutrition hypothesis is that a significant component of ASD risk might be effectively managed from a public policy perspective by implementing a carnitine surveillance and dietary supplementation strategy for women planning pregnancies and for women in their first trimester of pregnancy. We argue that this prediction deserves serious clinical interrogation.

Maternal Plasma l-Carnitine Reduction During Pregnancy Is Mainly Attributed to OCTN2-Mediated Placental Uptake and Does Not Result in Maternal Hepatic Fatty Acid β-Oxidation Decline

l-Carnitine (l-Car) plays a crucial role in fatty acid β-oxidation. However, the plasma l-Car concentration in women markedly declines during pregnancy, but the underlying mechanism and its consequences on maternal hepatic β-oxidation have not yet been clarified. Our results showed that the plasma l-Car level in mice at gestation day (GD) 18 was significantly lower than that in nonpregnant mice, and the mean fetal-to-maternal plasma l-Car ratio in GD 18 mice was 3.0. Carnitine/organic cation transporter 2 (OCTN2) was highly expressed in mouse and human placenta and upregulated as gestation proceeds in human placenta, whereas expressions of carnitine transporter (CT) 1, CT2, and amino acid transporter B^0,+ were extremely low. Further study revealed that renal peroxisome proliferator-activated receptor α (PPARα) and OCTN2 were downregulated and the renal l-Car level was reduced, whereas the urinary excretion of l-Car was lower in late pregnant mice than in nonpregnant mice. Meanwhile, progesterone (pregnancy-related hormone) downregulated the expression of renal OCTN2 via PPARα-mediated pathway, and inhibited the activity of OCTN2, but estradiol, corticosterone, and cortisol did not. Unexpectedly, the maternal hepatic level of l-Car and β-hydroxybutyrate (an indicator of mitochondrial β-oxidation), and mRNA levels of several enzymes involved in fatty acid β-oxidation in GD 18 mice were higher than that in nonpregnant mice. In conclusion, OCTN2 mediated l-Car transfer across the placenta played a major role in maternal plasma l-Car reduction during pregnancy, which did not subsequently result in maternal hepatic fatty acid β-oxidation decrease.

Analysis of amino acid and acyl carnitine profiles in maternal and fetal serum from preeclampsia patients

Objectives: To analyze and compare concentrations of amino acids (AAs) and acylcarnitine (AC) profiles in maternal-fetal serum from women with preeclampsia (PE) and to assess their use as possible predictors of PE.Methods: This is a retrospective study in which we enrolled a total of 38 pregnant women and their offspring. Pregnant women with PE (n = 14) and healthy pregnant control subjects (n = 24) participated voluntarily in the study. Maternal blood and cord blood were tested using dry blood spot (DBS) specimens, and we detected concentrations of 18 types of AAs and 31 types of AC by using high-performance liquid chromatography tandem mass spectrometry (HPLC-MS), and compared metabolites between the groups. We used logistic regression modeling to estimate the association of each metabolite with development of PE.Results: Concentrations of most AAs and AC in PE mothers were significantly higher than those in the group of control mothers. Cord plasma concentrations of AC in most PE mothers were significantly higher than those in controls; however, in PE, levels of cord plasma concentrations of most AAs were significantly lower, except for Gly, compared with controls. Levels of most AAs and AC were lower in the control and PE groups, with a tendency for lower levels in maternal blood compared to cord blood. Receiver operating characteristics (ROC) and areas under the curves (AUC) analyses using these metabolites did not predict PE individually.Conclusions: Maternal-fetal levels of AAs and AC were associated with PE. But the use of metabolites did not constitute a reliable method for use as a biomarker in the diagnosis of PE. Further prospective studies are needed to clarify the roles of different metabolites involved in the mechanism underlying the development of PE.

Longitudinal Metabolomic Profiling of Amino Acids and Lipids across Healthy Pregnancy

Pregnancy is characterized by a complexity of metabolic processes that may impact fetal development and ultimately, infant health outcomes. However, our understanding of whole body maternal and fetal metabolism during this critical life stage remains incomplete. The objective of this study is to utilize metabolomics to profile longitudinal patterns of fasting maternal metabolites among a cohort of non-diabetic, healthy pregnant women in order to advance our understanding of changes in protein and lipid concentrations across gestation, the biochemical pathways by which they are metabolized and to describe variation in maternal metabolites between ethnic groups. Among 160 pregnant women, amino acids, tricarboxylic acid (TCA) cycle intermediates, keto-bodies and non-esterified fatty acids were detected by liquid chromatography coupled with mass spectrometry, while polar lipids were detected through flow-injected mass spectrometry. The maternal plasma concentration of several essential and non-essential amino acids, long-chain polyunsaturated fatty acids, free carnitine, acetylcarnitine, phosphatidylcholines and sphingomyelins significantly decreased across pregnancy. Concentrations of several TCA intermediates increase as pregnancy progresses, as well as the keto-body β-hydroxybutyrate. Ratios of specific acylcarnitines used as indicators of metabolic pathways suggest a decreased beta-oxidation rate and increased carnitine palmitoyltransferase-1 enzyme activity with advancing gestation. Decreasing amino acid concentrations likely reflects placental uptake and tissue biosynthesis. The absence of any increase in plasma non-esterified fatty acids is unexpected in the catabolic phase of later pregnancy and may reflect enhanced placental fatty acid uptake and utilization for fetal tissue growth. While it appears that energy production through the TCA cycle increases as pregnancy progresses, decreasing patterns of free carnitine and acetylcarnitine as well as increased carnitine palmitoyltransferase-1 rate and β-hydroxybutyrate levels suggest a concomitant upregulation of ketogenesis to ensure sufficient energy supply in the fasting state. Several differences in metabolomic profiles between Hispanic and non-Hispanic women demonstrate phenotypic variations in prenatal metabolism which should be considered in future studies.

Abnormal Newborn Screening in a Healthy Infant of a Mother with Undiagnosed Medium-Chain Acyl-CoA Dehydrogenase Deficiency

A neonate with low blood free carnitine level on newborn tandem mass spectrometry screening was evaluated for possible carnitine transporter defect (CTD). The plasma concentration of free carnitine was marginally reduced, and the concentrations of acylcarnitines (including C6, C8, and C10:1) were normal on confirmatory tests. Organic acids in urine were normal. In addition, none of the frequent Faroese SLC22A5 mutations (p.N32S, c.825-52G>A) which are common in the Danish population were identified. Evaluation of the mother showed low-normal free carnitine, but highly elevated medium-chain acylcarnitines (C6, C8, and C10:1) consistent with medium-chain acyl-CoA dehydrogenase deficiency (MCADD). The diagnosis was confirmed by the finding of homozygous presence of the c.985A>G mutation in ACADM.

Low availability of carnitine precursors as a possible reason for the diminished plasma carnitine concentrations in pregnant women

BACKGROUND

It has been shown that plasma carnitine concentrations decrease markedly during gestation. A recent study performed with a low number of subjects suggested that this effect could be due to a low iron status which leads to an impairment of carnitine synthesis. The present study aimed to confirm this finding in a greater number of subjects. It was moreover intended to find out whether low carnitine concentrations during pregnancy could be due to a reduced availability of precursors of carnitine synthesis, namely trimethyllysine (TML) and gamma-butyrobetaine (BB).

METHODS

Blood samples of 79 healthy pregnant women collected at delivery were used for this study.

RESULTS

There was only a weak, non-significant (P > 0.05), correlation between plasma concentration of ferritin and those of free and total carnitine. There was no correlation between other parameters of iron status (plasma iron concentration, hemoglobin, MCV, MCH) and plasma concentration of free and total carnitine. There were, however, significant (P < 0.05) positive correlations between concentrations of TML and BB and those of free and total carnitine in plasma.

CONCLUSIONS

The results of this study suggest that an insufficient iron status is not the reason for low plasma carnitine concentrations observed in pregnant women. It is rather indicated that low plasma carnitine concentrations are caused by a low availability of precursors for carnitine synthesis during gestation.

Impaired arachidonic (20:4n-6) and docosahexaenoic (22:6n-3) acid synthesis by phenylalanine metabolites as etiological factors in the neuropathology of phenylketonuria

The recent literature on polyunsaturated fatty acid metabolism in phenylketonuria (PKU) is critically analyzed. The data suggest that developmental impairment of the accretion of brain arachidonic (20:4n-6) and docosahexaenoic (22:6n-3, DHA) acids is a major etiological factor in the microcephaly and mental retardation of uncontrolled PKU and maternal PKU. These fatty acids appear to be synthesized by the recently elucidated carnitine-dependent, channeled, mitochondrial fatty acid desaturases for which alpha-tocopherolquinone (alpha-TQ) is an essential enzyme cofactor. alpha-TQ can be synthesized either de novo or from alpha-tocopherol. The fetus and newborn would primarily rely on de novo alpha-TQ synthesis for these mitochondrial desaturases because of low maternal transfer of alpha-tocopherol. Homogentisate, a pivotal intermediate in the de novo pathway of alpha-TQ synthesis, is synthesized by 4-hydroxyphenylpyruvate dioxygenase. The major catabolic products of excess phenylalanine, viz. phenylpyruvate and phenyllactate, are proposed to inhibit alpha-TQ synthesis at the level of the dioxygenase reaction by competing with its 4-hydroxyphenylpyruvate substrate, thus leading to a developmental impairment of 20:4n-6 and 22:6n-3 synthesis in uncontrolled PKU and fetuses of PKU mothers. The data suggest that dietary supplementation with carnitine, 20:4n-6, and 22:6n-3 may have therapeutic value for PKU mothers and for PKU patients who have been shown to have a low plasma status of these essential metabolites.

Bioequivalence of endogenous substances facing homeostatic equilibria: an example with potassium

Oral administration of endogenous substances in most cases results in negligible net increases in baseline plasma concentrations, associated with high variability. This poses the problem of their bioequivalence. Using the data obtained from a bioequivalence investigation of potassium aspartate (test vs reference formulation), the authors demonstrate the inconsistency of bioequivalence based on plasma concentrations and standard methods. Potassium aspartate was given orally at a dose of 15.8 mmoles to 12 healthy volunteers as test and reference values according to a two-period, two-formulation, two-sequence design. The individual net values of the area under the curve of plasma concentration (AUC) and cumulative urinary excretion (CUE), both obtained with the test formulation as post-dose minus baseline, were multiplied by 2, 3, 4, 5 and 6 and added to the baseline in order to simulate the administration of increasing single doses of the test, assuming dose-linear kinetics. Data generated with the test formulation were compared with original data of the reference according to 90% confidence intervals. With AUC, bioequivalence of test and reference formulations was demonstrated with 1 : 1, 2 : 1 and 3 : 1 test to reference dose ratios. With CUE only the 1 : 1 dose ratio comparison produced bioequivalence. The authors conclude that bioequivalence of endogenous substances conducted with standard procedures in most cases is a useless exercise. With potassium and more generally with drugs cleared via urine, urinary excretion would reflect the extent of absorption more faithfully than AUC.

L-Carnitine moiety assay: an up-to-date reappraisal covering the commonest methods for various applications

L-Carnitine and its esters are typical endogenous substances. Their homeostatic equilibria are effectively controlled by various mechanisms which include rate-limiting enteral absorption, a multicomponent endogenous pool which is regulated according to a mammillary metabolism, an asymmetric body distribution and a saturable tubular reabsorption process leading to renal thresholds. In formal pharmacokinetic and metabolic investigations, the whole L-carnitine pool should be investigated, owing to the rapid interchange process between the various components of the pool. Free L-carnitine, as well as its acyl esters, must therefore be considered from an analytical viewpoint. L-Carnitine, acetyl-L-carnitine and total L-carnitine (the latter as an expression of the whole pool) can easily be assayed by enzyme or radioenzyme methods. Propionyl-L-carnitine and other esters containing fatty acids with more than three carbon atoms can be assayed using various HPLC approaches. Tandem mass spectrometry is another excellent approach to the assay of carnitine and its short-chain, medium-chain and long-chain esters. As L-carnitine contains a chiral carbon atom, the enantioselectivity of the assays is also considered in this review. Metabolites produced by enteral bacteria, namely tri-, di- and mono-methylamine, gamma-butyrobetaine, along with other systemic metabolites, namely trimethylamine N-oxide and N-nitroso dimethylamine, are very important in quantitative and toxicokinetic terms and require specific assay methods. This review covers the commonest methods of assaying carnitine and its esters, their impurities and pre-systemic and systemic metabolites and gives analytical details and information on their applications in pharmaceutics, biochemistry, pharmacokinetics and toxicokinetics.

First prenatal diagnosis of the carnitine transporter defect

We report the first attempt at prenatal diagnosis of the carnitine transporter defect in a fetus at high risk of having the disorder. Analysis of cultured CVS after prolonged culture predicted that the fetus was not affected but might be heterozygous for the carnitine transporter defect, but chromosome 15 satellite DNA markers showed no paternal contribution, suggesting that the CVS cells assayed were of predominantly maternal origin. Subsequent assay of cultured amniocytes predicted that the fetus would be affected, and this was confirmed in the newborn period. We conclude that prenatal diagnosis of the carnitine transporter defect is possible, but where results depend on extended culture of CVS, molecular studies should be performed to confirm genetic contributions from both parents.