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Vos EN, Demirbas D, Mangel M, Gozalbo MER, Levy HL, Berry GT. The treatment of biochemical genetic diseases: From substrate reduction to nucleic acid therapies. Mol Genet Metab 2023; 140:107693. [PMID: 37716025 DOI: 10.1016/j.ymgme.2023.107693] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/29/2023] [Accepted: 08/29/2023] [Indexed: 09/18/2023]
Abstract
Newborn screening (NBS) began a revolution in the management of biochemical genetic diseases, greatly increasing the number of patients for whom dietary therapy would be beneficial in preventing complications in phenylketonuria as well as in a few similar disorders. The advent of next generation sequencing and expansion of NBS have markedly increased the number of biochemical genetic diseases as well as the number of patients identified each year. With the avalanche of new and proposed therapies, a second wave of options for the treatment of biochemical genetic disorders has emerged. These therapies range from simple substrate reduction to enzyme replacement, and now ex vivo gene therapy with autologous cell transplantation. In some instances, it may be optimal to introduce nucleic acid therapy during the prenatal period to avoid fetopathy. However, as with any new therapy, complications may occur. It is important for physicians and other caregivers, along with ethicists, to determine what new therapies might be beneficial to the patient, and which therapies have to be avoided for those individuals who have less severe problems and for which standard treatments are available. The purpose of this review is to discuss the "Standard" treatment plans that have been in place for many years and to identify the newest and upcoming therapies, to assist the physician and other healthcare workers in making the right decisions regarding the initiation of both the "Standard" and new therapies. We have utilized several diseases to illustrate the applications of these different modalities and discussed for which disorders they may be suitable. The future is bright, but optimal care of the patient, including and especially the newborn infant, requires a deep knowledge of the disease process and careful consideration of the necessary treatment plan, not just based on the different genetic defects but also with regards to different variants within a gene itself.
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Affiliation(s)
- E Naomi Vos
- Division of Genetics & Genomics, Boston Children's Hospital; and Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States of America; Manton Center for Orphan Disease Research, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, United States of America.
| | - Didem Demirbas
- Division of Genetics & Genomics, Boston Children's Hospital; and Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States of America; Manton Center for Orphan Disease Research, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, United States of America.
| | - Matthew Mangel
- Division of Genetics & Genomics, Boston Children's Hospital; and Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States of America.
| | - M Estela Rubio Gozalbo
- Department of Pediatrics and Clinical Genetics, Maastricht University Medical Centre+, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands; GROW, Maastricht University, Minderbroedersberg 4-6, 6211 LK Maastricht, the Netherlands; MetabERN: European Reference Network for Hereditary Metabolic Disorders, Udine, Italy; UMD: United for Metabolic Diseases Member, Amsterdam, the Netherlands.
| | - Harvey L Levy
- Division of Genetics & Genomics, Boston Children's Hospital; and Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States of America.
| | - Gerard T Berry
- Division of Genetics & Genomics, Boston Children's Hospital; and Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States of America; Manton Center for Orphan Disease Research, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, United States of America.
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Ziegler SG, Kim J, Ehmsen JT, Vernon HJ. Inborn errors of amino acid metabolism - from underlying pathophysiology to therapeutic advances. Dis Model Mech 2023; 16:dmm050233. [PMID: 37994477 PMCID: PMC10690057 DOI: 10.1242/dmm.050233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 10/19/2023] [Indexed: 11/24/2023] Open
Abstract
Amino acids are organic molecules that serve as basic substrates for protein synthesis and have additional key roles in a diverse array of cellular functions, including cell signaling, gene expression, energy production and molecular biosynthesis. Genetic defects in the synthesis, catabolism or transport of amino acids underlie a diverse class of diseases known as inborn errors of amino acid metabolism. Individually, these disorders are rare, but collectively, they represent an important group of potentially treatable disorders. In this Clinical Puzzle, we discuss the pathophysiology, clinical features and management of three disorders that showcase the diverse clinical presentations of disorders of amino acid metabolism: phenylketonuria, lysinuric protein intolerance and homocystinuria due to cystathionine β-synthase (CBS) deficiency. Understanding the biochemical perturbations caused by defects in amino acid metabolism will contribute to ongoing development of diagnostic and management strategies aimed at improving the morbidity and mortality associated with this diverse group of disorders.
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Affiliation(s)
- Shira G. Ziegler
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Jiyoung Kim
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Jeffrey T. Ehmsen
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Hilary J. Vernon
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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3
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Prepok FF, Schnabel KK, Sumánszki C, Barta AG, Tislér A, Reismann P. Long-Term Renal Function in Adult Patients with Phenylketonuria. Nephron Clin Pract 2023; 148:195-203. [PMID: 37757776 DOI: 10.1159/000531913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 07/04/2023] [Indexed: 09/29/2023] Open
Abstract
INTRODUCTION In phenylketonuria (PKU), toxic phenylalanine (Phe) can harm other organs beyond the brain. Furthermore, the lifelong therapy of PKU consists of consumption of increased amounts of amino-acid mixture that provoke hyperfiltration in the glomeruli. Therefore, the adherence to therapy in PKU might influence the long-term kidney function in PKU patients. METHODS Data from 41 adult, early treated PKU patients were analyzed in this 10-year, retrospective, monocentric study. Two subgroups were created according to their therapy adherence: one with long-term blood Phe levels in the therapeutic range (<600 µmol/L), and one with suboptimal blood Phe levels. Renal function and metabolic parameters were collected over 10 years. Kidney function parameters were compared between the two groups and associations between blood Phe levels and kidney function were tested. RESULTS After 10 years, serum creatinine levels (p = 0.369) and estimated glomerular filtration rate (eGFR) (p = 0.723) did not change significantly from baseline in the good therapeutic group. The suboptimal therapeutic group's eGFR decreased in the same period (from 110.4 ± 14 mL/min/1.73 m2 to 94.2 ± 16 mL/min/1.73 m2, p = 0.017). At 10 years, the suboptimal therapeutic group had an increased serum creatinine level (81 ± 14.4 μmol/L vs. 71.5 ± 13 μmol/L, p = 0.038), and a decreased eGFR (94.2 ± 16 mL/min/1.73 m2 vs. 103.3 ± 13 mL/min/1.73 m2p = 0.031) compared to the good adhering group. Significant negative correlation between Phe levels and eGFR (r = -0.41, p = 0.008) was observed. CONCLUSION Long-term suboptimal therapy adherence in PKU patients with high blood Phe levels may lead to deterioration in kidney function.
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Affiliation(s)
| | | | - Csaba Sumánszki
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - András Gellért Barta
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - András Tislér
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Péter Reismann
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
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Alghamdi MA, O'Donnell‐Luria A, Almontashiri NA, AlAali WY, Ali HH, Levy HL. Classical phenylketonuria presenting as maternal PKU syndrome in the offspring of an intellectually normal woman. JIMD Rep 2023; 64:312-316. [PMID: 37701331 PMCID: PMC10494492 DOI: 10.1002/jmd2.12384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 07/06/2023] [Accepted: 07/11/2023] [Indexed: 09/14/2023] Open
Abstract
Phenylketonuria (PKU) is an autosomal recessive inborn error of metabolism resulting from a deficiency of phenylalanine hydroxylase (PAH). If untreated by dietary restriction of phenylalanine intake, impaired postnatal cognitive development results from the neurotoxic effects of excessive phenylalanine (Phe). Signs and symptoms include severe intellectual disability and behavior problems with a high frequency of seizures and variable microcephaly. Maternal PKU syndrome refers to fetal damage resulting in congenital abnormalities when the mother has untreated PKU during pregnancy. Here, we report an intellectually normal 32-year-old female who presented with recurrent pregnancy loss and two neonatal deaths with congenital heart disease, microcephaly, intrauterine growth restriction, and respiratory distress. She was diagnosed with PKU through exome sequencing performed for carrier testing with a homozygous pathogenic variant in the PAH gene, c.169_171del, p.(Glu57del) that is associated with classical PKU. Consistent with the genetic finding, she had a markedly increased plasma phenylalanine concentration of 1642 μmol/L (normal <100). This case demonstrates that recurrent pregnancy loss due to untreated maternal PKU may present as an initial finding in otherwise unsuspected classical PKU and illustrates that extreme degrees of variable expressivity may occur in classical PKU. Moreover, this case illustrates the value of genomic sequencing of women who experience recurrent pregnancy loss or neonatal anomalies.
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Affiliation(s)
- Malak Ali Alghamdi
- Harvard Medical SchoolBostonMassachusettsUSA
- Medical Genetic Division, Pediatric DepartmentCollege of Medicine, King Saud UniversityRiyadhSaudi Arabia
- Program in Medical and Population GeneticsBroad Institute of MIT and HarvardCambridgeMassachusettsUSA
| | - Anne O'Donnell‐Luria
- Harvard Medical SchoolBostonMassachusettsUSA
- Program in Medical and Population GeneticsBroad Institute of MIT and HarvardCambridgeMassachusettsUSA
- Division of Genetics and GenomicsBoston Children's HospitalBostonMassachusettsUSA
| | - Naif A. Almontashiri
- Center for Genetics and Inherited Diseases (CGID)Taibah UniversityMadinahSaudi Arabia
| | - Wajeih Y. AlAali
- Dr. Sulaiman Al Habib Medical GroupArryan HospitalRiyadhSaudi Arabia
| | - Hebatallah H. Ali
- Research Center, College of MedicineKing Saud UniversityRiyadhSaudi Arabia
| | - Harvey L. Levy
- Harvard Medical SchoolBostonMassachusettsUSA
- Program in Medical and Population GeneticsBroad Institute of MIT and HarvardCambridgeMassachusettsUSA
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Quarenghi M, Giana A, Turri Quarenghi R, Volonté F. Sleeve gastrectomy is feasible in obese patients with phenylketonuria: A case report and literature review. Int J Surg Case Rep 2023; 109:108458. [PMID: 37437324 PMCID: PMC10362251 DOI: 10.1016/j.ijscr.2023.108458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/15/2023] [Accepted: 06/27/2023] [Indexed: 07/14/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Patients with phenylketonuria (PKU) exhibit a high incidence of obesity. Currently, bariatric surgery remains the most effective long-term treatment for obese patients. However, limited data regarding the applicability of bariatric surgery to obese patients with PKU have been reported in the literature. CASE PRESENTATION A case involving a young woman, in whom sleeve gastrectomy was performed to manage obesity that was resistant to conservative therapy, is presented herein. CLINICAL DISCUSSION The present report is the first to describe sleeve gastrectomy in an obese patient with PKU. The surgery proceeded without complications. Furthermore, the patient's phenylalanine levels remained under control for the first 3 months after surgery, with no major neurological complications. The diet prescribed in the first few months after surgery is complex; nevertheless, it is feasible to follow if supervised by a dietary team specialised in rare metabolic diseases. CONCLUSION Bariatric surgery in this patient with PKU did not result in any major complications. Surgery is feasible but it is important for the dietetic team involved to have expertise in PKU management.
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Affiliation(s)
- Massimo Quarenghi
- Clinical Nutrition and Dietetics, Department of Internal Medicine, Ospedale Regionale La Carità, Ente Ospedaliero Cantonale, Locarno, Switzerland.
| | - Arianna Giana
- Clinical Nutrition and Dietetics, Department of Internal Medicine, Ospedale Regionale San Giovanni, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | | | - Francesco Volonté
- Department of Surgery, Lugano Regional Hospital, Ente Ospedaliero Cantonale, Lugano, Switzerland; Department of Surgery, Sant'Anna Clinic, Via Sant'Anna 1, 6924 Lugano, Switzerland
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Merkel M, Berg D, Brüggemann N, Classen J, Mainka T, Zittel S, Muntau AC. Characterisation and differential diagnosis of neurological complications in adults with phenylketonuria: literature review and expert opinion. J Neurol 2023:10.1007/s00415-023-11703-4. [PMID: 37081197 DOI: 10.1007/s00415-023-11703-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/31/2023] [Accepted: 04/01/2023] [Indexed: 04/22/2023]
Abstract
OBJECTIVE Phenylketonuria (PKU) is a rare inherited metabolic disorder characterised by elevated phenylalanine (Phe) concentrations that can exert neurotoxic effects if untreated or upon treatment discontinuation. This systematic review supported by expert opinion aims to raise awareness among the neurological community on neurological complications experienced by adults with PKU (AwPKU). METHODS The PubMed database was searched for articles on neurological signs and symptoms in AwPKU published before March 2022. In addition, two virtual advisory boards were held with a panel of seven neurologists and two metabolic physicians from Germany and Austria. Findings are supported by three illustrative patient cases. RESULTS Thirty-nine articles were included. Despite early diagnosis and treatment, neurological signs and symptoms (e.g. ataxia, brisk tendon reflexes, tremor, visual impairment) can emerge in adulthood, especially if treatment has been discontinued after childhood. In PKU, late-onset neurological deficits often co-occur with cognitive impairment and psychiatric symptoms, all of which can be completely or partially reversed through resumption of treatment. CONCLUSION Ideally, neurologists should be part of the PKU multidisciplinary team, either to bring lost to follow-up patients back to clinic or to manage symptoms in referred patients, considering that symptoms are often reversible upon regaining metabolic control. The current findings have been combined in a leaflet that will be disseminated among neurologists in Germany and Austria to create awareness.
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Affiliation(s)
- Martin Merkel
- Endokrinologikum Hamburg, Lornsenstraße 6, 22767, Hamburg, Germany.
- Asklepios Campus Hamburg, Semmelweis University, Hamburg, Germany.
| | - Daniela Berg
- Department of Neurology, Christian-Albrechts University, Kiel, Germany
| | | | - Joseph Classen
- Department of Neurology, Leipzig University Medical Center, Leipzig, Germany
| | - Tina Mainka
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
- Berlin Institute of Health at Charité Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Berlin, Germany
| | - Simone Zittel
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ania C Muntau
- University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Thomas L, Olson A, Romani C. The impact of metabolic control on cognition, neurophysiology, and well-being in PKU: A systematic review and meta-analysis of the within-participant literature. Mol Genet Metab 2023; 138:106969. [PMID: 36599257 DOI: 10.1016/j.ymgme.2022.106969] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 12/09/2022] [Accepted: 12/10/2022] [Indexed: 12/15/2022]
Abstract
Phenylketonuria (PKU) is a metabolic disease where Phenylalanine (Phe) rises much above normal levels. Cross-sectional and correlational studies provide valuable information on the importance of maintaining low blood-Phe to achieve good outcomes, but they may be confounded, at least partially, by differences in participant demographics. Moreover, the effect of Phe at older ages is difficult to ascertain because of strong associations between Phe levels across ages. Within-participant studies avoid confounding issues. We have reviewed these studies. We followed PRISMA guidelines to search the literature for studies reporting the impact of Phe changes within participants. Phe was either increased or decreased through diet relaxation/resumption or through pharmacological interventions. Forty-six separate articles reported, singly or in combination, results on cognition (N = 37), well-being (N = 22) and neurophysiological health (N = 14). For all studies, we established, in a binary way, whether a benefit of lower Phe was or was not demonstrated and compared numbers showing benefit versus a null or negative outcome. We then analyzed whether critical parameters (e.g., length of the study/condition for the change, size of Phe change achieved) influenced presence or absence of benefit. For a subset of studies that reported quantitative cognitive outcomes, we carried out a meta-analysis to estimate the size of change in cognitive performance associated with a change in Phe and its significance. There were significantly more studies with benefits than no benefits, both for cognitive and well-being outcomes, and a trend in this direction for neurophysiological outcomes. The meta-analysis showed a highly significant effect size both overall (0.55) and when studies with adults/adolescents were considered separately (0.57). There was some indication that benefits were easier to demonstrate when differences in Phe were larger and achieved across a longer period, but these effects were not always consistent. These results reinforce results from the literature by demonstrating the importance of lower Phe in children as well as in adolescents and adults, even when confounding factors in group composition are eliminated. The field would benefit from further studies where Phe levels are contrasted within-participants to ascertain how much Phe needs to be changed and for how long to see a difference and which measures demonstrate a difference (e.g., which cognitive tasks).
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van de Burgt N, van Doesum W, Grevink M, van Niele S, de Koning T, Leibold N, Martinez-Martinez P, van Amelsvoort T, Cath D. Psychiatric manifestations of inborn errors of metabolism: A systematic review. Neurosci Biobehav Rev 2023; 144:104970. [PMID: 36436739 DOI: 10.1016/j.neubiorev.2022.104970] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 11/19/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
Inborn errors of metabolism (IEMs) are characterized by deficits in metabolic enzymes as a result of an inherited disease, leading to the accumulation or decreased excretion of proteins, carbohydrates and lipids. Although IEMs are often diagnosed during childhood, adolescent and adult onset variants may be accompanied by less somatic and more psychiatric manifestations, which often hampers recognition by psychiatrists of the distinction between a primary and secondary psychiatric disorder. To help clinicians in the diagnostic process, we aimed to provide an overview of psychiatric manifestations in IEMs. Our literature search yielded 4380 records in total, of which 88 studies were included in the qualitative synthesis. Reported psychiatric disorders in adolescent and adult IEMs included depression, anxiety disorder, psychosis, attention deficit hyperactivity disorder, autism spectrum disorder, bipolar disorder and obsessive-compulsive disorder as assessed by semi-structured diagnostic interviews and validated questionnaires. A diagnostic screener and multidisciplinary IEM clinics are proposed to help clinicians during the diagnostic process, to prevent diagnostic delay and to raise awareness of the psychiatric manifestations among IEMs.
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Affiliation(s)
- Nikita van de Burgt
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNs), Faculty of Health and Life Sciences (FHML), Maastricht University, Maastricht, the Netherlands.
| | - Willem van Doesum
- Department of Psychiatry, University of Groningen and University Medical Center Groningen, Groningen, the Netherlands; Department of Specialized Training, GGZ Drenthe Mental Health Institute, Assen, the Netherlands
| | - Mirjam Grevink
- Department of Specialized Training, GGZ Drenthe Mental Health Institute, Assen, the Netherlands
| | - Stephanie van Niele
- Department of Specialized Training, GGZ Drenthe Mental Health Institute, Assen, the Netherlands
| | - Tom de Koning
- Department of Specialized Training, GGZ Drenthe Mental Health Institute, Assen, the Netherlands; Department of Neurology and Genetics, University of Groningen and University Medical Center Groningen, Groningen, the Netherlands; Department of Pediatrics, Lund University, Lund, Sweden
| | - Nicole Leibold
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNs), Faculty of Health and Life Sciences (FHML), Maastricht University, Maastricht, the Netherlands
| | - Pilar Martinez-Martinez
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNs), Faculty of Health and Life Sciences (FHML), Maastricht University, Maastricht, the Netherlands
| | - Therese van Amelsvoort
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNs), Faculty of Health and Life Sciences (FHML), Maastricht University, Maastricht, the Netherlands
| | - Danielle Cath
- Department of Psychiatry, University of Groningen and University Medical Center Groningen, Groningen, the Netherlands; Department of Specialized Training, GGZ Drenthe Mental Health Institute, Assen, the Netherlands
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Manti F, Caviglia S, Cazzorla C, Dicintio A, Pilotto A, Burlina AP. Expert opinion of an Italian working group on the assessment of cognitive, psychological, and neurological outcomes in pediatric, adolescent, and adult patients with phenylketonuria. Orphanet J Rare Dis 2022; 17:443. [PMID: 36544165 PMCID: PMC9769037 DOI: 10.1186/s13023-022-02488-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/15/2022] [Indexed: 12/24/2022] Open
Abstract
Phenylketonuria (PKU) is an inherited metabolic disease characterized by a defective conversion of phenylalanine (Phe) to tyrosine, potentially leading to Phe accumulation in the brain. Dietary restriction since birth has led to normal cognitive development. However, PKU patients can still develop cognitive or behavioral abnormalities and subtle neurological deficits. Despite the increasing evidence in the field, the assessment of neurocognitive, psychopathological, and neurological follow-up of PKU patients at different ages is still debated. The high interindividual variability in the cognitive outcome of PKU patients makes the specificity of the neurocognitive and behavioral assessment extremely challenging. In the present paper, a multidisciplinary panel of Italian PKU experts discussed different tools available for cognitive, psychopathological, and neurological assessment at different ages based on the existing literature and daily clinical practice. This study aims to provide evidence and a real-life-based framework for a specific clinical assessment of pediatric, adolescent, and adult patients affected by PKU.
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Affiliation(s)
- Filippo Manti
- grid.7841.aUnit of Child Neurology and Psychiatry, Department of Human Neuroscience, University of Rome La Sapienza, Rome, Italy
| | - Stefania Caviglia
- grid.414125.70000 0001 0727 6809Unit of Clinical Psychology, Department of Neurosciences, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Chiara Cazzorla
- grid.411474.30000 0004 1760 2630Division of Inborn Metabolic Diseases, Department of Pediatrics, University Hospital, Padua, Italy
| | - Annamaria Dicintio
- grid.488556.2Department of Metabolic Diseases and Clinical Genetics, Giovanni XXIII Children Hospital, Azienda Ospedaliero-Universitaria Consorziale Policlinico, 70126 Bari, Italy
| | - Andrea Pilotto
- grid.7637.50000000417571846Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
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Romani C, Olson A, Aitkenhead L, Baker L, Patel D, Spronsen FV, MacDonald A, Wegberg AV, Huijbregts S. Meta-analyses of cognitive functions in early-treated adults with phenylketonuria. Neurosci Biobehav Rev 2022; 143:104925. [PMID: 36283539 DOI: 10.1016/j.neubiorev.2022.104925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 10/07/2022] [Accepted: 10/21/2022] [Indexed: 11/05/2022]
Abstract
Our study estimated size of impairment for different cognitive functions in early-treated adults with PKU (AwPKU) by combining literature results in a meta-analytic way. We analysed a large set of functions (N = 19), each probed by different measures (average = 12). Data were extracted from 26 PKU groups and matched controls, with 757 AwPKU contributing 220 measures. Effect sizes (ESs) were computed using Glass' ∆ where differences in performance between clinical/PKU and control groups are standardized using the mean and standard deviation of the control groups. Significance was assessed using measures nested within independent PKU groups as a random factor. The weighted Glass' ∆ was - 0.44 for all functions taken together, and - 0.60 for IQ, both highly significant. Separate, significant impairments were found for most functions, but with great variability (ESs from -1.02 to -0.18). The most severe impairments were in reasoning, visual-spatial attention speed, sustained attention, visuo-motor control, and flexibility. Effect sizes were larger with speed than accuracy measures, and with visuo-spatial than verbal stimuli. Results show a specific PKU profile that needs consideration when monitoring the disease.
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Affiliation(s)
| | - Andrew Olson
- Psychology Department, University of Birmingham, UK.
| | | | - Lucy Baker
- Psychology Department, Aston University, UK.
| | | | | | - Anita MacDonald
- Birmingham Women' s and Children's NHS Foundation Trust, UK.
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11
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Brown AA, Clocksin HE, Abbene EE, Ursery M, Christ SE. The relationship between metabolic control and basal ganglia morphometry and function in individuals with early-treated phenylketonuria. Mol Genet Metab 2022; 137:249-256. [PMID: 36209659 DOI: 10.1016/j.ymgme.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/15/2022] [Accepted: 09/20/2022] [Indexed: 11/21/2022]
Abstract
Abnormalities of the cortical white matter are the most prominent and widely-reported neurological findings in individuals with early-treated phenylketonuria (ETPKU). Much less is known regarding the effects of ETPKU on gray matter structures in the brain such as the basal ganglia. Previous findings on basal ganglia in ETPKU have been mixed. The current study was designed to further elucidate the effects of ETPKU and elevated phe levels on the morphometry of basal ganglia structures (i.e., putamen, caudate nucleus, nucleus accumbens, and globus pallidus). High resolution magnetic resonance imaging (MRI) data was collected from a sample of 37 adults with ETPKU and a demographically-matched comparison group of 33 individuals without PKU. No overall group differences (ETPKU vs. non-PKU) in basal ganglia volumes were observed. However, within the ETPKU group, poorer metabolic control (as reflected by higher blood phenylalanine levels) was associated with larger putamen volume. Vertex-wise shape analysis revealed that the volume increase was accompanied by shape changes in the middle left putamen. Consistent with this area's role in motor control, a significant correlation between left putamen volume and motor performance was also observed. Additional research is needed to fully understand the cellular level processes underlying this effect as well as to better understand the clinical impact of these morphometric changes and their potential relation to treatment response.
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Affiliation(s)
- Alexander A Brown
- Department of Psychological Sciences, University of Missouri, Columbia, MO, USA
| | - Hayley E Clocksin
- Department of Psychological Sciences, University of Missouri, Columbia, MO, USA
| | - Emily E Abbene
- Department of Psychological Sciences, University of Missouri, Columbia, MO, USA
| | - Mikayla Ursery
- Department of Psychological Sciences, University of Missouri, Columbia, MO, USA
| | - Shawn E Christ
- Department of Psychological Sciences, University of Missouri, Columbia, MO, USA.
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Lotz-Havla AS, Katzdobler S, Nuscher B, Weiß K, Levin J, Havla J, Maier EM. Serum glial fibrillary acidic protein and neurofilament light chain in patients with early treated phenylketonuria. Front Neurol 2022; 13:1011470. [PMID: 36247773 PMCID: PMC9559705 DOI: 10.3389/fneur.2022.1011470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 09/12/2022] [Indexed: 12/01/2022] Open
Abstract
To pave the way for healthy aging in early treated phenylketonuria (ETPKU) patients, a better understanding of the neurological course in this population is needed, requiring easy accessible biomarkers to monitor neurological disease progression in large cohorts. The objective of this pilot study was to investigate the potential of glial fibrillary acidic protein (GFAP) and neurofilament light chain (NfL) as blood biomarkers to indicate changes of the central nervous system in ETPKU. In this single-center cross-sectional study, GFAP and NfL concentrations in serum were quantified using the Simoa® multiplex technology in 56 ETPKU patients aged 6–36 years and 16 age matched healthy controls. Correlation analysis and hierarchical linear regression analysis were performed to investigate an association with disease-related biochemical parameters and retinal layers assessed by optical coherence tomography. ETPKU patients did not show significantly higher GFAP concentrations (mean 73 pg/ml) compared to healthy controls (mean 60 pg/ml, p = 0.140). However, individual pediatric and adult ETPKU patients had GFAP concentrations above the healthy control range. In addition, there was a significant association of GFAP concentrations with current plasma tyrosine concentrations (r = −0.482, p = 0.036), a biochemical marker in phenylketonuria, and the retinal inner nuclear layer volume (r = 0.451, p = 0.04). There was no evidence of NfL alterations in our ETPKU cohort. These pilot results encourage multicenter longitudinal studies to further investigate serum GFAP as a complementary tool to better understand and monitor neurological disease progression in ETPKU. Follow-up investigations on aging ETPKU patients are required to elucidate the potential of serum NfL as biomarker.
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Affiliation(s)
- Amelie S. Lotz-Havla
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Sabrina Katzdobler
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Brigitte Nuscher
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Katharina Weiß
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Johannes Levin
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
- German Center for Neurodegenerative Diseases, site Munich, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Joachim Havla
- Institute of Clinical Neuroimmunology, University Hospital, LMU Munich, Munich, Germany
- Data Integration for Future Medicine (DIFUTURE) Consortium, LMU Munich, Munich, Germany
- *Correspondence: Joachim Havla
| | - Esther M. Maier
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
- Esther M. Maier
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Quinn J, Georgiadis A, Lewis HB, Jurecki E. Measuring Burden of Illness in Phenylketonuria (PKU): Development of the PKU Symptom Severity and Impacts Scale as a Robust Patient-Reported Outcome. Adv Ther 2022; 39:971-91. [PMID: 34921666 DOI: 10.1007/s12325-021-01986-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 11/05/2021] [Indexed: 11/29/2022]
Abstract
Introduction Phenylketonuria (PKU) is a rare, metabolic genetic disorder that can cause various neuropsychological symptoms that often affect patients’ health-related quality of life, even for patients with good metabolic control. To date, no patient-reported outcomes (PRO) instrument combines the measurement of neuropsychological and dietary concepts to capture the broad impact of PKU on quality of life. This article presents the development of the PKU Symptom Severity and Impacts Scale (PKU-SSIS), a PRO instrument that is designed to evaluate neuropsychological symptoms and impacts in early-treated patients with PKU. Methods A draft instrument was developed based on a targeted literature review, PKU expert physician interviews, and an advisory board consisting of patients with PKU. Qualitative interviews combining concept elicitation/cognitive interviews were conducted with patients with classic PKU aged at least 15 years old. A separate sample of 20 patients with PKU completed the draft PKU-SSIS in a paper survey format, to enable preliminary assessment of any floor and ceiling effects. Results Patient interviews elicited four key symptom themes: neurocognitive function, emotional and behavioral, physical functioning, and physical health. Four impact themes were also identified: social function, physical health, emotions, and level of independence. No floor or ceiling effects were identified. Conclusion The final instrument included 22 items, covering three symptom domains (1. emotional, mood, and psychological; 2. (neuro)cognitive, executive, and intellectual function; and 3. physical health), and four impact domains (1. social relations, 2. level of independence, 3. general well-being, and 4. self-care). The PKU-SSIS will help to address an important gap in the evaluation of existing and future treatments for PKU.
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Kenneson A, Singh RH. Natural history of children and adults with phenylketonuria in the NBS-PKU Connect registry. Mol Genet Metab 2021; 134:243-249. [PMID: 34654619 DOI: 10.1016/j.ymgme.2021.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 10/01/2021] [Accepted: 10/02/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Phenylalanine hydroxylase deficiency, or phenylketonuria (PKU), is a rare autosomal recessive metabolic disorder. Early diagnosis via newborn screening (NBS) and initiation of treatment prevent the development of cognitive impairment and other co-morbidities. The purpose of this study is to describe the natural history of PKU in the United States, including prevalence of co-morbidities and predictors of outcomes. METHODS We analyzed data from a self-report survey in the NBS-PKU Connect online registry. We describe the participants' nutrition management strategies, barriers to management, outcomes of bone disorders, skin, and psychological co-morbidities, and the use of special education or other special services. Predictors of outcomes were identified and assessed, including the impact of sex, age, age at diagnosis, blood phenylalanine concentration, use of sapropterin, use of medical food, adherence to prescribed diet, use of low protein modified foods, whether they had ever been off-diet, and use of tyrosine supplementation. RESULTS The 219 respondents included individuals with PKU or hyperphenylalanemia (n = 78), or their caregivers (n = 141). Most (84.3%) started treatment before the age of two weeks. About one-third indicated that they had been off-diet at some point in their lives, and 81.4% reported that they currently adhered to their prescribed diet, with adherence to prescribed diet decreasing with age. Blood phenylalanine concentration was under the recommended threshold of 360 μmol/L for 68.5% of participants. One-quarter of respondents reported psychological co-morbidities, with anxiety and ADD/ADHD being the most common. The incidence of psychological co-morbidities increased with age and with ever having been off diet. Special education or other special services were more likely to be reported by individuals who were diagnosed after one week of age. Skin disorders such as acne and eczema were more common in females than males, and a minority of participants reported bone disorders. CONCLUSIONS Despite recommendations to maintain blood phenylalanine concentrations in the therapeutic range throughout life, it is not uncommon for adults with PKU to discontinue dietary management of their disorder. Early diagnosis was associated with reduced need for special education or other special services, and continuous treatment was associated with decreased psychological co-morbidities.
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Affiliation(s)
- Aileen Kenneson
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, United States of America.
| | - Rani H Singh
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, United States of America; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States of America.
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15
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Kanufre V, Almeida MF, Barbosa CS, Carmona C, Bandeira A, Martins E, Rocha S, Guimas A, Ribeiro R, MacDonald A, Pinto A, Rocha JC. Metabolic Control of Patients with Phenylketonuria in a Portuguese Metabolic Centre Comparing Three Different Recommendations. Nutrients 2021; 13:3118. [PMID: 34578995 PMCID: PMC8469656 DOI: 10.3390/nu13093118] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 08/28/2021] [Accepted: 09/01/2021] [Indexed: 11/16/2022] Open
Abstract
Blood phenylalanine (Phe) is used as the primary marker to evaluate metabolic control. Our study aimed to describe the metabolic control of patients with phenylketonuria (PKU) comparing three different treatment recommendations (European guidelines/US guidelines/Portuguese consensus). This was a retrospective, observational, single centre study in patients with PKU collecting data on blood Phe levels from 2017. Nutritional intake data and sapropterin (BH4) prescription were collected at the last appointment of 2017. The final sample studied included 87 patients (48% females) [13 hyperphenylalaninemia; 47 mild PKU; 27 classical PKU] with a median age of 18 y (range: 1-36 y). The median number of blood Phe measurements for patients was 21 (range: 6-89). In patients aged < 12 y, the median blood Phe level was 300 μmol/L (range 168-480) and 474 μmol/L (range 156-1194) for patients ≥ 12 y. Overall, a median of 83% of blood Phe levels were within the European PKU guidelines target range. In patients aged ≥ 12 years, there was a higher median % of blood Phe levels within the European PKU guidelines target range (≥12 y: 84% vs. <12 y: 56%). In children < 12 y with classical PKU (n = 2), only 34% of blood Phe levels were within target range for all 3 guidelines and 49% with mild PKU (n = 11). Girls had better control than boys (89% vs. 66% median Phe levels within European Guidelines). Although it is clear that 50% or more patients were unable to achieve acceptable metabolic control on current treatment options, a globally agreed upper Phe target associated with optimal outcomes for age groups is necessary. More studies need to examine how clinics with dissimilar resources, different therapeutic Phe targets and frequency of monitoring relate to metabolic control.
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Affiliation(s)
- Viviane Kanufre
- Centro de Genética Médica, Centro Hospitalar Universitário do Porto (CHUPorto), 4099-028 Porto, Portugal; (V.K.); (M.F.A.); catarina-s-@hotmail.com (C.S.B.); (C.C.)
- Centro de Referência na Área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto-CHUPorto, 4099-001 Porto, Portugal; (A.B.); (E.M.); (S.R.); (A.G.); (R.R.)
- Núcleo de Ações e Pesquisa em Apoio Diagnóstico (NUPAD), School of Medicine, Federal University of Minas Gerais (UFMG), Avenida Professor Alfredo Balena, 190, Belo Horizonte 30130-100, Brazil
- Hospital das Clínicas, UFMG, Avenida Professor Alfredo Balena, 110, Santa Efigênia, Belo Horizonte 30130-100, Brazil
| | - Manuela Ferreira Almeida
- Centro de Genética Médica, Centro Hospitalar Universitário do Porto (CHUPorto), 4099-028 Porto, Portugal; (V.K.); (M.F.A.); catarina-s-@hotmail.com (C.S.B.); (C.C.)
- Centro de Referência na Área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto-CHUPorto, 4099-001 Porto, Portugal; (A.B.); (E.M.); (S.R.); (A.G.); (R.R.)
- Unit for Multidisciplinary Research in Biomedicine, Abel Salazar Institute of Biomedical Sciences, University of Porto-UMIB/ICBAS/UP, 4050-313 Porto, Portugal
| | - Catarina Sousa Barbosa
- Centro de Genética Médica, Centro Hospitalar Universitário do Porto (CHUPorto), 4099-028 Porto, Portugal; (V.K.); (M.F.A.); catarina-s-@hotmail.com (C.S.B.); (C.C.)
- Centro de Referência na Área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto-CHUPorto, 4099-001 Porto, Portugal; (A.B.); (E.M.); (S.R.); (A.G.); (R.R.)
| | - Carla Carmona
- Centro de Genética Médica, Centro Hospitalar Universitário do Porto (CHUPorto), 4099-028 Porto, Portugal; (V.K.); (M.F.A.); catarina-s-@hotmail.com (C.S.B.); (C.C.)
- Centro de Referência na Área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto-CHUPorto, 4099-001 Porto, Portugal; (A.B.); (E.M.); (S.R.); (A.G.); (R.R.)
- Unit for Multidisciplinary Research in Biomedicine, Abel Salazar Institute of Biomedical Sciences, University of Porto-UMIB/ICBAS/UP, 4050-313 Porto, Portugal
| | - Anabela Bandeira
- Centro de Referência na Área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto-CHUPorto, 4099-001 Porto, Portugal; (A.B.); (E.M.); (S.R.); (A.G.); (R.R.)
| | - Esmeralda Martins
- Centro de Referência na Área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto-CHUPorto, 4099-001 Porto, Portugal; (A.B.); (E.M.); (S.R.); (A.G.); (R.R.)
- Unit for Multidisciplinary Research in Biomedicine, Abel Salazar Institute of Biomedical Sciences, University of Porto-UMIB/ICBAS/UP, 4050-313 Porto, Portugal
| | - Sara Rocha
- Centro de Referência na Área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto-CHUPorto, 4099-001 Porto, Portugal; (A.B.); (E.M.); (S.R.); (A.G.); (R.R.)
| | - Arlindo Guimas
- Centro de Referência na Área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto-CHUPorto, 4099-001 Porto, Portugal; (A.B.); (E.M.); (S.R.); (A.G.); (R.R.)
| | - Rosa Ribeiro
- Centro de Referência na Área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto-CHUPorto, 4099-001 Porto, Portugal; (A.B.); (E.M.); (S.R.); (A.G.); (R.R.)
| | - Anita MacDonald
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (A.M.); (A.P.)
| | - Alex Pinto
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (A.M.); (A.P.)
| | - Júlio César Rocha
- Centro de Genética Médica, Centro Hospitalar Universitário do Porto (CHUPorto), 4099-028 Porto, Portugal; (V.K.); (M.F.A.); catarina-s-@hotmail.com (C.S.B.); (C.C.)
- Centro de Referência na Área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto-CHUPorto, 4099-001 Porto, Portugal; (A.B.); (E.M.); (S.R.); (A.G.); (R.R.)
- Nutrition & Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Campo Mártires da Pátria, 130, 1169-056 Lisbon, Portugal
- Centre for Health Technology and Services Research (CINTESIS), 4200-450 Porto, Portugal
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Mainka T, Fischer JF, Huebl J, Jung A, Lier D, Mosejova A, Skorvanek M, de Koning TJ, Kühn AA, Freisinger P, Ziagaki A, Ganos C. The neurological and neuropsychiatric spectrum of adults with late-treated phenylketonuria. Parkinsonism Relat Disord 2021; 89:167-175. [PMID: 34391119 DOI: 10.1016/j.parkreldis.2021.06.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 06/02/2021] [Accepted: 06/16/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Phenylketonuria (PKU) is a rare, treatable inborn error of metabolism with frequent neurological and neuropsychiatric complications, especially in undiagnosed or insufficiently treated individuals. Given the wide range of clinical presentations and the importance of treatment implications, we here delineate the neurological and neuropsychiatric symptom spectrum in a large cohort of previously unreported adults with late-treated PKU. METHODS We consecutively evaluated late-treated PKU cases and pooled clinical and paraclinical data, including video-material, from three centers with expertise in complex movement disorders, inborn errors of metabolism and pediatrics. RESULTS 26 individuals were included (10 females, median age 52 years). Developmental delay and intellectual disability were omnipresent with severe impairment of expressive communication noted in 50% of cases. Movement disorders were prevalent (77%), including tremor (38%, mostly postural), stereotypies (38%), and tics (19%). One case had neurodegenerative levodopa-responsive parkinsonism. Mild ataxia was noted in 54% of cases and 31% had a history of seizures. Neuropsychiatric characteristics included obsessive-compulsive (35%) and self-injurious behaviors (31%), anxiety (27%), depression (19%) and features compatible with those observed in individuals with autism spectrum disorder (19%). Neuroimaging revealed mild white matter changes. Adherence to dietary treatment was inconsistent in the majority of cases, particularly throughout adolescence. CONCLUSION A history of movement disorders, particularly tremor, stereotypies and tics, in the presence of developmental delay, intellectual disability and neuropsychiatric features, such as obsessive-compulsive and self-injurious behaviors in adults should prompt the diagnostic consideration of PKU. Initiation and adherence to (dietary) treatment can ameliorate the severity of these symptoms.
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Affiliation(s)
- Tina Mainka
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany; Berlin Institute of Health, Berlin, Germany
| | | | - Julius Huebl
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany; Department of Neurology, Klinikum Bogenhausen, Städtisches Klinikum München GmbH, Munich, Germany
| | - Alexandra Jung
- Interdisciplinary Center of Metabolism: Endocrinology, Diabetes and Metabolism, University-Medicine Berlin, Campus Virchow-Klinikum, Germany
| | - Dinah Lier
- Department of Pediatrics, Klinikum Reutlingen, Reutlingen, Germany
| | - Alexandra Mosejova
- Department of Neurology, P.J. Safarik University, Košice, Slovakia; Department of Neurology, University Hospital L. Pasteur, Košice, Slovakia
| | - Matej Skorvanek
- Department of Neurology, P.J. Safarik University, Košice, Slovakia; Department of Neurology, University Hospital L. Pasteur, Košice, Slovakia
| | - Tom J de Koning
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Pediatrics, Department of Clinical Sciences, Lund University, Sweden
| | - Andrea A Kühn
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Peter Freisinger
- Department of Pediatrics, Klinikum Reutlingen, Reutlingen, Germany
| | - Athanasia Ziagaki
- Interdisciplinary Center of Metabolism: Endocrinology, Diabetes and Metabolism, University-Medicine Berlin, Campus Virchow-Klinikum, Germany
| | - Christos Ganos
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany.
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Serfozo C, Barta AG, Horvath E, Sumanszki C, Csakany B, Resch M, Nagy ZZ, Reismann P. Reduced macular thickness and macular vessel density in early-treated adult patients with PKU. Mol Genet Metab Rep 2021; 27:100767. [PMID: 34026550 DOI: 10.1016/j.ymgmr.2021.100767] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/27/2021] [Accepted: 04/28/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose Macular structure is poorly evaluated in early-treated phenylketonuria (ETPKU). To evaluate potential changes, we aimed to examine retinas of PKU patients using optical coherence tomography (OCT) with additional OCT angiography (OCTA) and compare the results to healthy controls. Methods A total of 100 adults were recruited in this monocentric, case-control study: 50 patients with ETPKU (mean age: 30.66 ± 8.00 years) and 50 healthy controls (mean age: 30.45 ± 7.18 years). Macular thickness, vessel density and flow area of the right eye was assessed with spectral domain OCT angiography SD-OCT(A). Macular microstructural data between the ETPKU and control group was compared. In the ETPKU group, the relationship between visual functional parameters (best corrected visual acuity [VA], spherical equivalent [SE], contrast sensitivity [CS] and near stereoacuity) and microstructural alterations was examined. The dependency of OCT(A) values on serum phenylalanine (Phe) level was analysed. Results There was significant average parafoveal and perifoveal total retinal layer thinning in ETPKU patients compared to healthy controls (p < 0.016 and p < 0.001, respectively), while the foveal region remained unchanged in the ETPKU group. Whole macular and parafoveal superficial capillary plexus density was significantly decreased in ETPKU compared to controls (p < 0.001). There were no significant differences in the foveal avascular zone, nonflow area, macular superficial and deep capillary plexus between the groups. The temporal parafoveal inner retinal layer thickness was found to negatively correlate with individual Phe levels (r = -0.35, p = 0.042). There was no difference in vascular density and retinal thickness in the subgroup analysis of patients with good therapy adherence compared to patients on a relaxed diet. Conclusions Durable elevation in Phe levels are only partially associated with macular retinal structural changes. However, therapy adherence might not influence these ophthalmological complications.
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Key Words
- Dopamine
- Macular retinal vessel density
- Macular thickness
- Optical Coherence Tomography Angiography, (OCTA)
- Optical Coherence Tomography, (OCT)
- Optical coherence tomography angiography
- Parkinson's disease, (PD)
- Phenylalanine level
- Phenylalanine, (Phe)
- Phenylketonuria
- Tyrosine, (Tyr)
- aminoacid supplements, (AAS)
- axial length, (AL)
- contrast sensitivity, (CS)
- deep capillary plexus, (DCP)
- diopters, (D)
- dopamine, (DA)
- early treated phenylketonuria, (ETPKU)
- external limiting membrane/inner segment of photoreceptors/outer segment of photoreceptors, (ELM/IS/OS)
- ganglion cell complex, (GCC)
- ganglion cell layer, (GCL)
- inner limiting membrane, (ILM)
- inner nuclear layer, (INL)
- inner plexiform layer, (IPL)
- inner retinal layer, (IRL)
- intraocular pressure, (IOP)
- outer nuclear layer, (ONL)
- outer plexiform layer, (OPL)
- outer retinal layer, (ORL)
- phenylalanine hydroxylase gene, (PAH)
- phenylketonuria, (PKU)
- retinal nerve fiber layer, (RNFL)
- retinal pigment epithelium, (RPE)
- signal strength index, (SSI)
- sine-wave contrast test, (SWCT)
- spectral domain, (SD)
- spherical equivalent, (SE)
- split-spectrum amplitude-decorrelation angiography, (SSADA)
- superficial capillary plexus, (SCP)
- tetrahydrobiopterin, (BH4)
- total retinal layer thickness, (TRLT)
- vessel density, (VD)
- visual acuity, (VA)
- visual evoked potential, (VEP)
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Thiele AG, Spieß N, Ascherl R, Arelin M, Rohde C, Kiess W, Beblo S. Psychological well-being of early and continuously treated phenylketonuria patients. JIMD Rep 2021; 59:69-80. [PMID: 33977032 PMCID: PMC8100406 DOI: 10.1002/jmd2.12202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 01/07/2021] [Accepted: 01/13/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Despite enormous advances in therapy, phenylketonuria (PKU) remains an incurable, inherited metabolic disease requiring life-long treatment with potential to negatively impact quality of life and psychological well-being. Therefore, the aim of this study was to screen early diagnosed and continuously treated children with PKU on psychological strengths and behavioral difficulties. METHODS Evaluation of psychological strengths and behavioral difficulties in 49 patients with PKU (23f, 2-17 years) by Strengths and Difficulties Questionnaire (SDQ; self-report 11-17 years and parent-report 2-17 years). Comparison to age, sex and BMI-matched healthy controls (n = 98; 46f). RESULTS In patients with PKU and healthy controls median SDQ Total Difficulties Score and median scores of subscales were within the normal range in parent- and self-report, irrespective of sex and age group (children 2-10 years, adolescents 11-17 years). No influence of long-term metabolic control in PKU on SDQ could be revealed. The 2- to 10-year-old boys with PKU showed significantly higher scores in Prosocial Behavior compared to their healthy peers (P = .032). Likewise, adolescent boys with PKU showed fewer Conduct Problems (parent-report, P = .006). Adolescent girls with PKU rated themselves more often as abnormal in the subscale Emotional Problems compared to their healthy peers (P = .041). This subscale was also responsible for a significantly different Total SDQ Difficulties Score between patients and their parents' report (P = .008). DISCUSSION SDQ represents a suitable instrument within the care for patients with PKU. Specific aspects, however, require separate consideration and evaluation with respect to this chronic disease. Special attention should be paid on adolescent PKU girls who seem to be at risk to develop emotional problem.
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Affiliation(s)
- Alena Gerlinde Thiele
- Hospital for Children and Adolescents, Center for Pediatric Research Leipzig (CPL), Department of Women and Child Health, University Hospital, University of LeipzigLeipzigGermany
| | - Nicole Spieß
- Hospital for Children and Adolescents, Center for Pediatric Research Leipzig (CPL), Department of Women and Child Health, University Hospital, University of LeipzigLeipzigGermany
- Present address:
Internistisches Therapiezentrum (ITZ)Habichtswald‐Klinik Kassel, Wigandstraße 1, 34131KasselGermany
| | - Rudolf Ascherl
- Hospital for Children and Adolescents, Center for Pediatric Research Leipzig (CPL), Department of Women and Child Health, University Hospital, University of LeipzigLeipzigGermany
| | - Maria Arelin
- Hospital for Children and Adolescents, Center for Pediatric Research Leipzig (CPL), Department of Women and Child Health, University Hospital, University of LeipzigLeipzigGermany
| | - Carmen Rohde
- Hospital for Children and Adolescents, Center for Pediatric Research Leipzig (CPL), Department of Women and Child Health, University Hospital, University of LeipzigLeipzigGermany
| | - Wieland Kiess
- Hospital for Children and Adolescents, Center for Pediatric Research Leipzig (CPL), Department of Women and Child Health, University Hospital, University of LeipzigLeipzigGermany
| | - Skadi Beblo
- Hospital for Children and Adolescents, Center for Pediatric Research Leipzig (CPL), Department of Women and Child Health, University Hospital, University of LeipzigLeipzigGermany
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Hamie L, Eid E, Khalil J, Touma Sawaya R, Abbas O, Kurban M. Genodermatoses with behavioural sequelae. Postgrad Med J 2021; 98:799-810. [PMID: 37062993 DOI: 10.1136/postgradmedj-2020-139539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 03/30/2021] [Accepted: 04/06/2021] [Indexed: 11/04/2022]
Abstract
Children with genodermatoses are at an increased risk of developing behavioural disorders which may impart lasting damage on the individual and their family members. As such, early recognition of childhood mental health disorders via meticulous history taking, thorough physical examination, and disorder-specific testing is of paramount importance for timely and effective intervention. If carried out properly, prompt psychiatric screening and intervention can effectively mitigate, prevent or even reverse, the psychiatric sequela in question. To that end, this review aims to inform the concerned physician of the manifestations and treatment strategies relevant to the psychological sequelae of genodermatoses.
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Affiliation(s)
- Lamiaa Hamie
- Department of Dermatology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Edward Eid
- Department of Dermatology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Joanna Khalil
- Department of Dermatology, American University of Beirut Medical Center, Beirut, Lebanon
| | | | - Ossama Abbas
- Department of Dermatology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mazen Kurban
- Department of Dermatology, American University of Beirut Medical Center, Beirut, Lebanon .,Department of Biochemistry and Molecular Genetics, American University of Beirut, Beirut, Lebanon.,Division of Genomics and Translational Biomedicine, College of Health and Life Sciences, Hamad Bin Khalifa University, Doha, Qatar
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20
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Yamada K, Yamaguchi S, Yokoyama K, Aoki K, Taketani T. Long-Term Neurological Outcomes of Adult Patients with Phenylketonuria before and after Newborn Screening in Japan. Int J Neonatal Screen 2021; 7. [PMID: 33919983 DOI: 10.3390/ijns7020021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/29/2021] [Accepted: 04/12/2021] [Indexed: 11/17/2022] Open
Abstract
Japanese newborn screening (NBS) for phenylketonuria (PKU) was initiated in 1977. We surveyed the neurological outcomes of Japanese adult patients with PKU to investigate the long-term effects and of and issues with NBS. Eighty-five patients with PKU aged over 19 years who continued to be treated with a phenylalanine-free amino acid formula were investigated by administering questionnaires regarding clinical characteristics, such as mental ability, education status, and therapeutic condition. Of the 85 subjects, 68 patients were detected by NBS (NBS group), while the other 17 were clinically diagnosed before the initiation of NBS (pre-NBS group). Further, 10 of the 68 NBS patients presented intellectual and/or psychiatric disabilities, 5 of whom had a history of treatment discontinuation; in contrast, 12 of the 17 pre-NBS patients presented with neuropsychiatric symptoms. Regarding social outcomes, almost all patients in the NBS group could live an independent life, while over half of the patients in the pre-NBS group were not employed or lived in nursing-care facilities. Neurological outcomes are obviously improved by NBS in Japan. However, some patients, even those detected by NBS, developed neuropsychiatric symptoms due to treatment disruption. Lifelong and strict management is essential to maintain good neurological and social prognoses for patients with PKU.
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21
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Burgess NM, Kelso W, Malpas CB, Winton-Brown T, Fazio T, Panetta J, De Jong G, Neath J, Atherton S, Velakoulis D, Walterfang M. The effect of improved dietary control on cognitive and psychiatric functioning in adults with phenylketonuria: the ReDAPT study. Orphanet J Rare Dis 2021; 16:35. [PMID: 33461585 PMCID: PMC7814424 DOI: 10.1186/s13023-020-01668-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 12/22/2020] [Indexed: 11/16/2022] Open
Abstract
Background Phenylketonuria (PKU) is an autosomal recessive inherited disorder characterised by a deficiency in phenylalanine hydroxylase. Untreated, PKU is associated with a wide range of cognitive and psychiatric sequelae. Contemporary management guidelines recommend lifetime dietary control of phenylalanine (Phe) levels, however many individuals who discontinue dietary control subsequently suffer symptoms of anxiety, depression and disturbances to cognition. We undertook a prospective cohort study of patients with early-treated phenylketonuria who had ceased dietary control to test the hypothesis that resumption of dietary control of PKU is associated with improvements in measures of psychiatric morbidity and cognitive functioning. Methods We re-initiated dietary control for early-treated patients with PKU and monitored cognitive and psychiatric outcomes over a twelve-month period. Assessments included objective cognitive function (measured by cognitive proficiency index (CPI)), anxiety and depression scales. General linear mixed model (GLMM) analyses were performed to assess change in psychometric variables from baseline over twelve months after resumption of dietary control. Results A total of nine patients were recruited. Mean age was 33 years (SD = 8.75), five were female. Mean time off dietary control was 19.1 years (SD = 11.3), and mean baseline phenylalanine (Phe) levels were 1108 µmol/L (SD = 293). GLMM analysis demonstrated a positive relationship between CPI and time on diet (b = 0.56 [95% CI = 0.17, 0.95]). Age, time off diet, Phe levels and depression scores were not associated with cognitive function. There was a negative relationship between time on diet and anxiety (b = − 0.88 95% CI = [− 1.26, − 0.50]) and depression ratings (b = − 0.61, 95% CI = [− 0.95, − 0.26]). Conclusions This study demonstrated improvements in cognitive function, anxiety, and depression ratings associated with resumption of dietary control of PKU. Raw Phe levels were not strongly associated with psychiatric or cognitive scores in this cohort. These findings support the importance of lifelong treatment for PKU in improving the cognitive and psychiatric sequelae of the disease.
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Affiliation(s)
- Nicholas M Burgess
- Neuropsychiatry Unit, Royal Melbourne Hospital, Level 2, John Cade Building, Melbourne,, 3050, Australia
| | - Wendy Kelso
- Neuropsychiatry Unit, Royal Melbourne Hospital, Level 2, John Cade Building, Melbourne,, 3050, Australia
| | - Charles B Malpas
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia.,Clinical Outcomes Research Unit (CORe), Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Toby Winton-Brown
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Timothy Fazio
- Department of Metabolic Medicine, Royal Melbourne Hospital, Melbourne, Australia.,Melbourne Medical School, Department of Medicine and Radiology, University of Melbourne, Parkville, Australia
| | - Julie Panetta
- Department of Metabolic Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Gerard De Jong
- Department of Metabolic Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Joanna Neath
- Neuropsychiatry Unit, Royal Melbourne Hospital, Level 2, John Cade Building, Melbourne,, 3050, Australia
| | | | - Dennis Velakoulis
- Neuropsychiatry Unit, Royal Melbourne Hospital, Level 2, John Cade Building, Melbourne,, 3050, Australia.,Melbourne Neuropsychiatry Centre, University of Melbourne and North-Western Mental Health, Melbourne, Australia
| | - Mark Walterfang
- Neuropsychiatry Unit, Royal Melbourne Hospital, Level 2, John Cade Building, Melbourne,, 3050, Australia. .,Melbourne Neuropsychiatry Centre, University of Melbourne and North-Western Mental Health, Melbourne, Australia. .,Florey Institute of Neuroscience and Mental Health, Melbourne, Australia.
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22
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Lowe TB, DeLuca J, Arnold G. Neurocognitive, neuropsychiatric, and neurological outcomes associated with phenylalanine hydroxylase deficiency: Assessment considerations for nurse practitioners. J SPEC PEDIATR NURS 2021; 26:e12312. [PMID: 32956570 DOI: 10.1111/jspn.12312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 05/11/2020] [Accepted: 09/03/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of this article is to review literature for neurocognitive, neuropsychiatric, neurological complications associated with phenylalanine hydroxylase (PAH) deficiency. The goal is to familiarize nurse practitioners with treatment and monitoring guidelines for persons living with the disorder. CONCLUSIONS Appropriate treatment can maximize neurocognitive and neuropsychiatric outcomes. PRACTICE IMPLICATIONS Nurse practitioners can help persons with PAH deficiency through education and providing appropriate referrals and by supporting disease-specific treatment.
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Affiliation(s)
- Tracy B Lowe
- Healthcare Genetics, Clemson University, Clemson, South Carolina, USA
| | - Jane DeLuca
- Clemson University, Clemson, South Carolina, USA
| | - Georgianne Arnold
- Medical Genetics Clinical Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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23
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Koppes EA, Redel BK, Johnson MA, Skvorak KJ, Ghaloul-Gonzalez L, Yates ME, Lewis DW, Gollin SM, Wu YL, Christ SE, Yerle M, Leshinski A, Spate LD, Benne JA, Murphy SL, Samuel MS, Walters EM, Hansen SA, Wells KD, Lichter-Konecki U, Wagner RA, Newsome JT, Dobrowolski SF, Vockley J, Prather RS, Nicholls RD. A porcine model of phenylketonuria generated by CRISPR/Cas9 genome editing. JCI Insight 2020; 5:141523. [PMID: 33055427 PMCID: PMC7605535 DOI: 10.1172/jci.insight.141523] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 09/17/2020] [Indexed: 12/17/2022] Open
Abstract
Phenylalanine hydroxylase-deficient (PAH-deficient) phenylketonuria (PKU) results in systemic hyperphenylalaninemia, leading to neurotoxicity with severe developmental disabilities. Dietary phenylalanine (Phe) restriction prevents the most deleterious effects of hyperphenylalaninemia, but adherence to diet is poor in adult and adolescent patients, resulting in characteristic neurobehavioral phenotypes. Thus, an urgent need exists for new treatments. Additionally, rodent models of PKU do not adequately reflect neurocognitive phenotypes, and thus there is a need for improved animal models. To this end, we have developed PAH-null pigs. After selection of optimal CRISPR/Cas9 genome-editing reagents by using an in vitro cell model, zygote injection of 2 sgRNAs and Cas9 mRNA demonstrated deletions in preimplantation embryos, with embryo transfer to a surrogate leading to 2 founder animals. One pig was heterozygous for a PAH exon 6 deletion allele, while the other was compound heterozygous for deletions of exon 6 and of exons 6-7. The affected pig exhibited hyperphenylalaninemia (2000-5000 μM) that was treatable by dietary Phe restriction, consistent with classical PKU, along with juvenile growth retardation, hypopigmentation, ventriculomegaly, and decreased brain gray matter volume. In conclusion, we have established a large-animal preclinical model of PKU to investigate pathophysiology and to assess new therapeutic interventions.
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Affiliation(s)
- Erik A Koppes
- Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh School of Medicine, and Universityof Pittsburgh Medical Center (UPMC) Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Bethany K Redel
- Division ofAnimal Sciences, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, Missouri, USA.,National Swine Research and Resource Center (NSRRC), College of Veterinary Medicine, University of Missouri, Columbia, Missouri, USA
| | - Marie A Johnson
- Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh School of Medicine, and Universityof Pittsburgh Medical Center (UPMC) Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kristen J Skvorak
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Lina Ghaloul-Gonzalez
- Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh School of Medicine, and Universityof Pittsburgh Medical Center (UPMC) Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Human Genetics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Megan E Yates
- Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh School of Medicine, and Universityof Pittsburgh Medical Center (UPMC) Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dale W Lewis
- Department of Human Genetics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Susanne M Gollin
- Department of Human Genetics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Yijen L Wu
- Department of Developmental Biology, University of Pittsburgh, and UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Shawn E Christ
- Department of Psychological Sciences, University of Missouri, Columbia, Missouri, USA
| | - Martine Yerle
- GenPhySE, Université de Toulouse, INRAE, ENVT, 31326, Castanet-Tolosan, France
| | - Angela Leshinski
- Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh School of Medicine, and Universityof Pittsburgh Medical Center (UPMC) Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lee D Spate
- Division ofAnimal Sciences, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, Missouri, USA.,National Swine Research and Resource Center (NSRRC), College of Veterinary Medicine, University of Missouri, Columbia, Missouri, USA
| | - Joshua A Benne
- National Swine Research and Resource Center (NSRRC), College of Veterinary Medicine, University of Missouri, Columbia, Missouri, USA
| | - Stephanie L Murphy
- National Swine Research and Resource Center (NSRRC), College of Veterinary Medicine, University of Missouri, Columbia, Missouri, USA
| | - Melissa S Samuel
- Division ofAnimal Sciences, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, Missouri, USA.,National Swine Research and Resource Center (NSRRC), College of Veterinary Medicine, University of Missouri, Columbia, Missouri, USA
| | - Eric M Walters
- Division ofAnimal Sciences, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, Missouri, USA.,National Swine Research and Resource Center (NSRRC), College of Veterinary Medicine, University of Missouri, Columbia, Missouri, USA
| | - Sarah A Hansen
- Department of Veterinary Pathobiology, College of Veterinary Medicine, University of Missouri, Columbia, Missouri, USA
| | - Kevin D Wells
- Division ofAnimal Sciences, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, Missouri, USA.,National Swine Research and Resource Center (NSRRC), College of Veterinary Medicine, University of Missouri, Columbia, Missouri, USA
| | - Uta Lichter-Konecki
- Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh School of Medicine, and Universityof Pittsburgh Medical Center (UPMC) Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert A Wagner
- Division of Laboratory Animal Resources, Office of Research, Health Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joseph T Newsome
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Division of Laboratory Animal Resources, Office of Research, Health Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Steven F Dobrowolski
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jerry Vockley
- Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh School of Medicine, and Universityof Pittsburgh Medical Center (UPMC) Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Human Genetics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Randall S Prather
- Division ofAnimal Sciences, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, Missouri, USA.,National Swine Research and Resource Center (NSRRC), College of Veterinary Medicine, University of Missouri, Columbia, Missouri, USA
| | - Robert D Nicholls
- Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh School of Medicine, and Universityof Pittsburgh Medical Center (UPMC) Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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24
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Klimek A, Baerwald C, Schwarz M, Rutsch F, Parhofer KG, Plöckinger U, Heddrich-Ellerbrok M, Vom Dahl S, Schöne K, Ott M, Lang F, Hennermann JB. Everyday Life, Dietary Practices, and Health Conditions of Adult PKU Patients: A Multicenter, Cross-Sectional Study. Ann Nutr Metab 2020; 76:251-258. [PMID: 32998147 DOI: 10.1159/000510260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 07/16/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Only few data on dietary management of adult phenylketonuria (PKU) patients are published. OBJECTIVES This study aimed to assess living situation, dietary practices, and health conditions of early-treated adult PKU patients. METHODS A total of 183 early-treated PKU patients ≥18 years from 8 German metabolic centers received access to an online survey, containing 91 questions on sociodemographic data, dietary habits, and health conditions. RESULTS 144/183 patients (66% females) completed the questionnaire. Compared with German population, the proportion of single-person households was higher (22 vs. 47%), the rate of childbirth was lower (1.34 vs. 0.4%), but educational and professional status did not differ. 82% of the patients adhered to a low-protein diet, 45% consumed modified low-protein food almost daily, and 84% took amino acid mixtures regularly. 48% of the patients never interrupted diet, and 14% stopped diet permanently. 69% of the patients reported to feel better with diet, and 91% considered their quality of life at least as good. The prevalence of depressive symptoms was high (29%) and correlated significantly to phenylalanine blood concentrations (p = 0.046). However, depressive symptoms were only mild in the majority of patients. CONCLUSION This group of early-treated adult German PKU patients is socially well integrated, reveals a surprisingly high adherence to diet and amino acid intake, and considers the restrictions of diet to their daily life as low.
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Affiliation(s)
- Annemarie Klimek
- Villa Metabolica, Department of Pediatric and Adolescent Medicine, University Medical Center Mainz, Mainz, Germany
| | - Christoph Baerwald
- Rheumatology Unit, Department of Internal Medicine, Neurology and Dermatology, University Medical Center Leipzig, Leipzig, Germany
| | - Martin Schwarz
- Practice Cooperation and Training Practice Kaarst, Kaarst, Germany
| | - Frank Rutsch
- Department of Pediatrics, University Medical Center Münster, Münster, Germany
| | - Klaus G Parhofer
- Medical Department IV - Grosshadern, University Munich, Munich, Germany
| | - Ursula Plöckinger
- Interdisciplinary Center of Metabolism: Endocrinology, Diabetes and Metabolism, Charité University Medicine Berlin, Berlin, Germany
| | | | - Stephan Vom Dahl
- Department for Gastroenterology, Hepatology and Infectious Diseases, University Medical Center Düsseldorf, Düsseldorf, Germany
| | - Klaus Schöne
- Institute for Teachers' Health, University Medical Center Mainz, Mainz, Germany
| | - Markus Ott
- Nutricia GmbH, Metabolics Expert Centre DACH, Frankfurt, Germany
| | - Frauke Lang
- Villa Metabolica, Department of Pediatric and Adolescent Medicine, University Medical Center Mainz, Mainz, Germany
| | - Julia B Hennermann
- Villa Metabolica, Department of Pediatric and Adolescent Medicine, University Medical Center Mainz, Mainz, Germany,
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25
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Serfozo C, Barta AG, Horvath E, Sumanszki C, Csakany B, Resch M, Nagy ZZ, Reismann P. Altered visual functions, macular ganglion cell and papillary retinal nerve fiber layer thickness in early-treated adult PKU patients. Mol Genet Metab Rep 2020; 25:100649. [PMID: 32995291 PMCID: PMC7516291 DOI: 10.1016/j.ymgmr.2020.100649] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/07/2020] [Accepted: 09/08/2020] [Indexed: 12/12/2022] Open
Abstract
Purpose Retinal changes are poorly described in early treated phenylketonuria (ETPKU). We aimed to investigate possible visual functional and ocular microstructural changes in adult patients with ETPKU. Optical coherence tomography (OCT) and its angiography (OCTA) data from patients with PKU were compared to healthy controls. Methods In this prospective, monocentric, cross-sectional, case-control study 50 patients with ETPKU and 50 healthy subjects were evaluated with OCT and OCTA. Measurements were performed on right eyes. The following visual function parameters were studied: best corrected visual acuity (BCVA), spherical equivalent (SE), contrast sensitivity and near stereoacuity; microstructural parameters: retinal nerve fiber layer thickness (RNFLT), ganglion cell layer (GCC) thickness, focal loss of volume (FLV), global loss of volume (GLV), peripapillary, papillary vessel density (VD), ocular axial length (AL) and intraocular pressure (IOP). Results Among functional tests there were significant differences in contrast sensitivity at 1.5 (p < 0.001), 6 (p < 0.013), 12 (p < 0.001), 18 (p < 0.003) cycles per degree, in near stereoacuity (Titmus Wirt circles, p < 0.001) and in best corrected visual acuity (BCVA, p < 0.001). A statistically significant, moderate positive linear correlation was observed between BCVA and average Phe levels over the last ten years (β = 0.49, p < 0.001). The average (p < 0.001), superior (p < 0.001) inferior GCC (p < 0.001), the FLV (p < 0.003), GLV (p < 0.001) and the average RNFLT (p < 0.004) values of the PKU group were significantly lower than the controls. The serum phenylalanine level (Phe) in the PKU group negatively correlated with inferior (−0.32, p < 0.007), superior (r = −0.26, p < 0.028) and average (−0.29 p < 0.014) RNFL and with AL (−0.32, p < 0.026). In AL we detected a significant difference (p < 0.04) between the good and suboptimal dietary controlled group. There was no significant difference between the ETPKU and control group in the measured vessel density parameters and in IOP. Conclusions Our results suggest that functional and ocular microstructural defects are present in patients with PKU, and some of them may depend on dietary control. The mechanism is unclear, but the correlation indicates the importance of strict dietary control in terms of preservation of retinal functions.
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Key Words
- AAS, aminoacid supplements
- AL, axial length
- BCVA, best corrected visual acuity
- BH4, Tetrahydrobiopterine
- D, diopters
- DA, dopamine
- Dopamine
- ETDRS, early treatment diabetic retinopathy study
- ETPKU, early-treated phenylketonuria
- FLV, focal loss of volume
- GCC, ganglion cell layer thickness
- GLV, global loss of volume
- GMP, Glycomacropeptide
- Ganglion cell layer thickness
- IOP, intraocular pressure
- LogMAR, logarithm of the minimum angle of resolution
- Myopia
- OCT, optical coherence tomography
- OCTA, optical coherence tomography angiography
- Optical coherence tomography angiography
- PD, Parkinson's disease
- PKU, phenylketonuria
- Phe, phenylalanine
- Phenylalanine level
- Phenylketonuria
- RNFL, retinal nerve fiber layer
- RNFLT, retinal nerve fiber layer thickness
- Retinal nerve fiber layer thickness
- SD, spectral domain
- SE, spherical equivalent
- SWCT, sine wave contrast test
- VD, vessel density
- VEPs, Visual evoked potentials
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Affiliation(s)
- Csilla Serfozo
- Department of Ophthalmology, Faculty of Medicine, Semmelweis University, Maria utca 39, Budapest 1085, Hungary
| | - Andras Gellert Barta
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Koranyi Sandor utca 2/a, Budapest 1083, Hungary
| | - Endre Horvath
- Independent statistician, H-1171, Alsodabas park 4/2, Budapest, Hungary
| | - Csaba Sumanszki
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Koranyi Sandor utca 2/a, Budapest 1083, Hungary
| | - Bela Csakany
- Department of Ophthalmology, Faculty of Medicine, Semmelweis University, Maria utca 39, Budapest 1085, Hungary
| | - Miklos Resch
- Department of Ophthalmology, Faculty of Medicine, Semmelweis University, Maria utca 39, Budapest 1085, Hungary
| | - Zoltan Zsolt Nagy
- Department of Ophthalmology, Faculty of Medicine, Semmelweis University, Maria utca 39, Budapest 1085, Hungary
| | - Peter Reismann
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Koranyi Sandor utca 2/a, Budapest 1083, Hungary
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26
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Abstract
AbstractAlthough chronic traumatic encephalopathy (CTE) garners substantial attention in the media and there have been marked scientific advances in the last few years, much remains unclear about the role of genetic risk in CTE. Two athletes with comparable contact-sport exposure may have varying amounts of CTE neuropathology, suggesting that other factors, including genetics, may contribute to CTE risk and severity. In this review, we explore reasons why genetics may be important for CTE, concepts in genetic study design for CTE (including choosing controls, endophenotypes, gene by environment interaction, and epigenetics), implicated genes in CTE (including APOE, MAPT, and TMEM106B), and whether predictive genetic testing for CTE should be considered.
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Affiliation(s)
- Bobak Abdolmohammadi
- Boston University Alzheimer’s Disease Center, Boston University School of Medicine, Boston, MA
- Boston University Chronic Traumatic Encephalopathy Center, Boston University School of Medicine, Boston, MA
- Department of Neurology, Boston University School of Medicine, Boston, MA
| | - Alicia Dupre
- Boston University Alzheimer’s Disease Center, Boston University School of Medicine, Boston, MA
- Boston University Chronic Traumatic Encephalopathy Center, Boston University School of Medicine, Boston, MA
- Department of Neurology, Boston University School of Medicine, Boston, MA
| | - Laney Evers
- Boston University Alzheimer’s Disease Center, Boston University School of Medicine, Boston, MA
- Boston University Chronic Traumatic Encephalopathy Center, Boston University School of Medicine, Boston, MA
- Department of Neurology, Boston University School of Medicine, Boston, MA
| | - Jesse Mez
- Boston University Alzheimer’s Disease Center, Boston University School of Medicine, Boston, MA
- Boston University Chronic Traumatic Encephalopathy Center, Boston University School of Medicine, Boston, MA
- Department of Neurology, Boston University School of Medicine, Boston, MA
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27
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Abstract
BACKGROUND Phenylketonuria is an inherited disease treated with dietary restriction of the amino acid phenylalanine. The diet is initiated in the neonatal period to prevent learning disability; however, it is restrictive and can be difficult to follow. Whether the diet can be relaxed or discontinued during adolescence or should be continued for life remains a controversial issue, which we aim to address in this review. This is an updated version of a previously published review. OBJECTIVES To assess the effects of a low-phenylalanine diet commenced early in life for people with phenylketonuria. To assess the possible effects of relaxation or termination of the diet on intelligence, neuropsychological outcomes and mortality, growth, nutritional status, eating behaviour and quality of life. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearches of relevant journals and abstract books of conference proceedings. Most recent search of the Inborn Errors of Metabolism Trials Register: 30 April 2020. SELECTION CRITERIA All randomised or quasi-randomised controlled trials comparing a low-phenylalanine diet to relaxation or termination of dietary restrictions in people with phenylketonuria. DATA COLLECTION AND ANALYSIS Two authors independently assessed study eligibility and methodological quality, and subsequently extracted the data. MAIN RESULTS We included four studies in this review (251 participants), and found few significant differences between treatment and comparison groups for the outcomes of interest. Blood phenylalanine levels were significantly lower in participants with phenylketonuria following a low-phenylalanine diet compared to those on a less restricted diet, mean difference (MD) at three months -698.67 (95% confidence interval (CI) -869.44 to -527.89). Intelligence quotient was significantly higher in participants who continued the diet than in those who stopped the diet, MD after 12 months 5.00 (95% CI 0.40 to 9.60). However, these results came from a single study. AUTHORS' CONCLUSIONS The results of non-randomised studies have concluded that a low-phenylalanine diet is effective in reducing blood phenylalanine levels and improving intelligence quotient and neuropsychological outcomes. We were unable to find any randomised controlled studies that have assessed the effect of a low-phenylalanine diet versus no diet from diagnosis. In view of evidence from non-randomised studies, such a study would be unethical and it is recommended that low-phenylalanine diet should be commenced at the time of diagnosis. There is uncertainty about the precise level of phenylalanine restriction and when, if ever, the diet should be relaxed. This should be addressed by randomised controlled studies; however, no new studies are expected in this area so we do not plan to update this review.
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Affiliation(s)
- Elisabeth Jameson
- Willink Biochemical Genetics Unit, Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Tracey Remmington
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
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28
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Caletti MT, Bettocchi I, Baronio F, Brodosi L, Cataldi S, Petroni ML, Cassio A, Marchesini G. Maternal PKU: Defining phenylalanine tolerance and its variation during pregnancy, according to genetic background. Nutr Metab Cardiovasc Dis 2020; 30:977-983. [PMID: 32409273 DOI: 10.1016/j.numecd.2020.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 02/11/2020] [Accepted: 02/12/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND AIMS Phenylketonuria (PKU)-affected women may become pregnant, and dietary phenylalanine (Phe) intake must be adjusted according to Phe tolerance. We report our experience with maternal PKU in relation to genotype PKU heterogeneity. METHODS AND RESULTS A total of 10 pregnancies in 7 PKU women (7 different genotypes) were followed up as part of personalized care. Phe tolerance during preconception and pregnancy was assessed by strict dietary control and weekly Phe measurement (blood spots) in relation to genotype. Most women had stopped PKU diet during childhood or adolescence and six pregnancies were unplanned; a phenylalanine-restricted diet was reinstituted soon after conception. Women were classified according to their Phe levels at birth screening and genotype. Phe tolerance increased systematically in the course of pregnancy in all cases, but the increase was different in subjects with classic PKU (cPKU) when compared with cases with mild hyperphenylalaninemia (mHPA), both on average (+297 mg/day in cPKU vs. 597 in mHPA; P = 0.017) and as percentage (+107% in cPKU vs. +17% in mHPA). Notably, Phe tolerance also varied in the same women in the course of different pregnancies, when body weight gain was also different. Two newborns from the same cPKU mother (unplanned pregnancies on free diet) were affected by congenital alterations. CONCLUSIONS Several factors influence metabolic phenotype in maternal PKU, to an unpredictable extent even in the same woman. The number of maternal PKU cases is growing in dedicated Nutrition Units, and the burden associated with careful management of this condition for the health care system should be adequately considered.
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Affiliation(s)
- Maria T Caletti
- Unit of Metabolic Diseases and Clinical Dietetics - DIMEC, "Alma Mater" University, Bologna, Italy
| | - Ilaria Bettocchi
- Unit of Pediatrics - DIMEC, "Alma Mater" University, Bologna, Italy
| | - Federico Baronio
- Unit of Pediatrics - DIMEC, "Alma Mater" University, Bologna, Italy
| | - Lucia Brodosi
- Unit of Metabolic Diseases and Clinical Dietetics - DIMEC, "Alma Mater" University, Bologna, Italy
| | - Sara Cataldi
- Unit of Metabolic Diseases and Clinical Dietetics - DIMEC, "Alma Mater" University, Bologna, Italy
| | - Maria L Petroni
- Unit of Metabolic Diseases and Clinical Dietetics - DIMEC, "Alma Mater" University, Bologna, Italy
| | | | - Giulio Marchesini
- Unit of Metabolic Diseases and Clinical Dietetics - DIMEC, "Alma Mater" University, Bologna, Italy.
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Barta AG, Sumánszki C, Turgonyi Z, Kiss E, Simon E, Serfőző C, Reismann P. Health Related Quality of Life assessment among early-treated Hungarian adult PKU patients using the PKU-QOL adult questionnaire. Mol Genet Metab Rep 2020; 23:100589. [PMID: 32346514 PMCID: PMC7183227 DOI: 10.1016/j.ymgmr.2020.100589] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/12/2020] [Accepted: 04/13/2020] [Indexed: 11/27/2022] Open
Abstract
Background: The implementation of neonatal screening and the early initiation of lifelong therapy have helped to prevent severe complications and enabled much more favorable outcomes for early-treated phenylketonuria (ETPKU) patients. However, PKU patients tend to develop subtle cognitive and psychosocial abnormalities and the strict dietary therapy can present financial and social burden. Thus, PKU is expected to affect the quality of life (QoL) of these patients. There is insufficient evidence regarding the relationship between metabolic control and Health-Related QoL (HRQoL). We aimed to assess the effect of short- and long-term therapy on QoL among Hungarian adult PKU patients using the standardized PKU-specific PKU-QoL questionnaire. Methods: We conducted a single-centre, cross-sectional, observational study in Hungary. We included adult PKU patients treated with diet and amino acid supplements only. Patients reported HRQoL using the standardized adult PKU-QoL questionnaire and mean blood Phe concentrations were assessed for three different time periods: the previous 10 years, the previous year and concentration at the time of completing the questionnaire. The correlation between patients’ QoL scores and their Phe levels was assessed. The classical PKU group was further divided into “good” and “suboptimal” adherence groups based on individual mean Phe levels in the examined time period. We evaluated differences in QoL among the two subgroups of classical PKU patients. QoL scores between classical and non-classical patients were also compared. Results: Data from 88 adult patients were analysed (66 had classical PKU). No median PKU-QoL score reached major or severe impact/frequent symptoms in any domain. The highest scores (meaning larger burden) were mostly related to emotional impact of PKU and disease management. When performing correlation analysis between Phe levels and QoL scores by all patients we found weak to fair positive correlation in several domains either short or long term. Patients with classical PKU reported greater financial impact of PKU than patients with less severe PKU. Classical PKU patients with good therapy adherence tended to report better HRQoL scores than patients with suboptimal adherence. Conclusion: We conclude that patients showed good HRQoL using the PKU-specific questionnaire. Our study demonstrates that suboptimal metabolic control is negatively associated with patients' HRQoL.
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Key Words
- AAS, amino acid supplements
- Adult
- ETPKU, early-treated phenylketonuria
- Early treated
- GMP, glycomacropeptide
- HPA, hyperphenylalaninaemia
- HRQoL
- HRQoL, health related quality of life
- Health related quality of life
- IQR, interquartile range
- PKU
- PKU, phenylketonuria
- PKU-QoL, Phenylketonuria Quality of Life questionnaires
- Phe, phenylalanine
- Phenylketonuria
- SD, standard deviation
- Tyr, tyrosine
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Affiliation(s)
- András Gellért Barta
- 2 Department of Internal Medicine, Semmelweis University,Szentkirályi street 46, Budapest 1088, Hungary
| | - Csaba Sumánszki
- 2 Department of Internal Medicine, Semmelweis University,Szentkirályi street 46, Budapest 1088, Hungary
| | - Zsófia Turgonyi
- Faculty of Medicine, Semmelweis University, Üllői út 26, Budapest 1085, Hungary
| | - Erika Kiss
- 1 Department of Pediatrics, Semmelweis University, Bokay J. street 53-54, Budapest 1083, Hungary
| | - Erika Simon
- 1 Department of Pediatrics, Semmelweis University, Bokay J. street 53-54, Budapest 1083, Hungary
| | - Csilla Serfőző
- Department of Ophthalmology, Semmelweis University, Mária street 39, Budapest 1085, Hungary
| | - Péter Reismann
- 2 Department of Internal Medicine, Semmelweis University,Szentkirályi street 46, Budapest 1088, Hungary
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Vardy ERLC, MacDonald A, Ford S, Hofman DL. Phenylketonuria, co-morbidity, and ageing: A review. J Inherit Metab Dis 2020; 43:167-178. [PMID: 31675115 DOI: 10.1002/jimd.12186] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/27/2019] [Accepted: 10/28/2019] [Indexed: 12/17/2022]
Abstract
Phenylketonuria (PKU) is a metabolic condition which, left untreated, results in severe and irreversible brain damage. Newborn screening and the development of the low phenylalanine (Phe) diet have transformed the outcomes for people with PKU. Those who have benefited from early treatment are now approaching their fifth and sixth decade. It is therefore timely to consider multi-morbidity in PKU and the effects of ageing, in parallel with the wider benefits of emerging treatment options in addition to dietary relaxation. We have conducted the first literature review of co-morbidity and ageing in the context of PKU. Avenues explored have emerged from limited study of multi-morbidity to date and the knowledge and critical enquiry of the authors. Findings suggest PKU to have a wider impact than brain development, and result in several intriguing questions that require investigation to attain the best outcomes for people with PKU in adulthood moving through to older age. We recognise the difficulty in studying longitudinal outcomes in rare diseases and emphasise the necessity to develop PKU registries and cohorts that facilitate well-designed studies to answer some of the questions raised in this review. Whilst awaiting new information in these areas we propose that clinicians engage with patients to make personalised and well-informed decisions around Phe control and assessment for co-morbidity.
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Affiliation(s)
- Emma R L C Vardy
- Department of Ageing and Complex Medicine, Salford Royal NHS Foundation Trust, Salford Care Organisation, Part of Northern Care Alliance NHS Group, Salford, UK
| | - Anita MacDonald
- Department of dietetics, Birmingham Women's and Children's NHS Trust, Birmingham, UK
| | - Suzanne Ford
- National Society for Phenylketonuria, Preston, UK
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Harding CO. Prospects for Cell-Directed Curative Therapy of Phenylketonuria (PKU). Mol Front J 2019; 3:110-121. [PMID: 32524084 PMCID: PMC7286632 DOI: 10.1142/s2529732519400145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Phenylketonuria (PKU) due to recessively inherited phenylalanine hydroxylase (PAH) deficiency is among the most common inborn errors of metabolism. Dietary therapy begun early in infancy prevents the major manifestations of the disease but shortcomings to treatment continue to exist including lifelong commitment to a complicated and unpalatable diet, poor adherence to diet in adolescence and adulthood, and consequently a range of unsatisfactory outcomes, including neuropsychiatric disorders, frequently develop. Novel treatments that do not strictly depend upon dietary protein restriction are actively sought. This review discusses the potential for and the limitations of permanently curative cell-directed treatment of PKU, including liver-directed gene therapy and gene editing, if initiated during early infancy. A fictional but realistic vignette of a family with a new baby girl recently diagnosed with PKU is presented. What is needed to permanently cure her?
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Affiliation(s)
- Cary O Harding
- Department of Molecular and Medical Genetics, Oregon Health & Science University, Mailstop L-103, 3181 Sam Jackson Park Rd., Portland, OR 97239, USA
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Palermo L, MacDonald A, Limback E, Robertson L, Howe S, Geberhiwot T, Romani C. Emotional health in early-treated adults with phenylketonuria (PKU): Relationship with cognitive abilities and blood phenylalanine. J Clin Exp Neuropsychol 2019; 42:142-159. [DOI: 10.1080/13803395.2019.1696753] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Liana Palermo
- School of Life and Health Sciences, Aston University, Birmingham, UK
- Inherited Metabolic Disorders Service, Queen Elizabeth Hospital, Birmingham, UK
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Anita MacDonald
- Dietetic Department, Birmingham Children’s Hospital, Birmingham, UK
| | - Ellie Limback
- School of Life and Health Sciences, Aston University, Birmingham, UK
| | - Louise Robertson
- Inherited Metabolic Disorders Service, Queen Elizabeth Hospital, Birmingham, UK
| | - Sarah Howe
- Inherited Metabolic Disorders Service, Queen Elizabeth Hospital, Birmingham, UK
| | - Tarekegn Geberhiwot
- Inherited Metabolic Disorders Service, Queen Elizabeth Hospital, Birmingham, UK
| | - Cristina Romani
- School of Life and Health Sciences, Aston University, Birmingham, UK
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Romani C, Manti F, Nardecchia F, Valentini F, Fallarino N, Carducci C, De Leo S, MacDonald A, Palermo L, Leuzzi V. Adult cognitive outcomes in phenylketonuria: explaining causes of variability beyond average Phe levels. Orphanet J Rare Dis 2019; 14:273. [PMID: 31779649 PMCID: PMC6883518 DOI: 10.1186/s13023-019-1225-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 10/09/2019] [Indexed: 11/10/2022] Open
Abstract
Objective The objective was to deepen the understanding of the causes of individual variability in phenylketonuria (PKU) by investigating which metabolic variables are most important for predicting cognitive outcomes (Phe average vs Phe variation) and by assessing the risk of cognitive impairment associated with adopting a more relaxed approach to the diet than is currently recommended. Method We analysed associations between metabolic and cognitive measures in a mixed sample of English and Italian early-treated adults with PKU (N = 56). Metabolic measures were collected through childhood, adolescence and adulthood; cognitive measures were collected in adulthood. Metabolic measures included average Phe levels (average of median values for each year in a given period) and average Phe variations (average yearly standard deviations). Cognition was measured with IQ and a battery of cognitive tasks. Results Phe variation was as important, if not more important, than Phe average in predicting adult outcomes and contributed independently. Phe variation was particularly detrimental in childhood. Together, childhood Phe variation and adult Phe average predicted around 40% of the variation in cognitive scores. Poor cognitive scores (> 1 SD from controls) occurred almost exclusively in individuals with poor metabolic control and the risk of poor scores was about 30% higher in individuals with Phe values exceeding recommended thresholds. Conclusions Our results provide support for current European guidelines (average Phe value = < 360 μmol/l in childhood; = < 600 μmo/l from 12 years onwards), but they suggest an additional recommendation to maintain stable levels (possibly Phe SD = < 180 μmol/l throughout life). Public significance statements We investigated the relationship between how well people with phenylketonuria control blood Phe throughout their life and their ability to carry out cognitive tasks in adulthood. We found that avoiding blood Phe peaks was as important if not more important that maintaining average low Phe levels. This was particularly essential in childhood. We also found that blood Phe levels above recommended European guidelines was associated with around 30% increase in the risk of poor cognitive outcomes.
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Affiliation(s)
- Cristina Romani
- School of Life and Health Sciences, Aston University, Aston Triangle, Birmingham, England, B4 7ET, UK.
| | - Filippo Manti
- Department of Human Neuroscience - Unit of Child Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Francesca Nardecchia
- Department of Human Neuroscience - Unit of Child Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | | | | | - Claudia Carducci
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Sabrina De Leo
- Department of Clinical Medicine, Policlinico Umberto I, Rome, Italy
| | - Anita MacDonald
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Liana Palermo
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Vincenzo Leuzzi
- Department of Human Neuroscience - Unit of Child Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
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Grisch-Chan HM, Schwank G, Harding CO, Thöny B. State-of-the-Art 2019 on Gene Therapy for Phenylketonuria. Hum Gene Ther 2019; 30:1274-1283. [PMID: 31364419 PMCID: PMC6763965 DOI: 10.1089/hum.2019.111] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 07/22/2019] [Indexed: 12/21/2022] Open
Abstract
Phenylketonuria (PKU) is considered to be a paradigm for a monogenic metabolic disorder but was never thought to be a primary application for human gene therapy due to established alternative treatment. However, somewhat unanticipated improvement in neuropsychiatric outcome upon long-term treatment of adults with PKU with enzyme substitution therapy might slowly change this assumption. In parallel, PKU was for a long time considered to be an excellent test system for experimental gene therapy of a Mendelian autosomal recessive defect of the liver due to an outstanding mouse model and the easy to analyze and well-defined therapeutic end point, that is, blood l-phenylalanine concentration. Lifelong treatment by targeting the mouse liver (or skeletal muscle) was achieved using different approaches, including (1) recombinant adeno-associated viral (rAAV) or nonviral naked DNA vector-based gene addition, (2) genome editing using base editors delivered by rAAV vectors, and (3) by delivering rAAVs for promoter-less insertion of the PAH-cDNA into the Pah locus. In this article we summarize the gene therapeutic attempts of correcting a mouse model for PKU and discuss the future implications for human gene therapy.
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Affiliation(s)
- Hiu Man Grisch-Chan
- Division of Metabolism, University Children's Hospital Zurich and Children's Research Centre, Zurich, Switzerland
| | - Gerald Schwank
- Department of Biology, Institute for Molecular Health Sciences, ETH Zurich, Zurich, Switzerland
| | - Cary O. Harding
- Department of Molecular and Medical Genetics, School of Medicine, Oregon Science and Health University, Portland, Oregon
| | - Beat Thöny
- Division of Metabolism, University Children's Hospital Zurich and Children's Research Centre, Zurich, Switzerland
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SriBhashyam S, Marsh K, Quartel A, Weng HH, Gershman A, Longo N, Thomas J, Zori R. A benefit-risk analysis of pegvaliase for the treatment of phenylketonuria: A study of patients' preferences. Mol Genet Metab Rep 2019; 21:100507. [PMID: 31497506 PMCID: PMC6722251 DOI: 10.1016/j.ymgmr.2019.100507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/20/2019] [Accepted: 08/20/2019] [Indexed: 12/02/2022] Open
Abstract
Background Phenylketonuria (PKU) leads to an accumulation of phenylalanine (Phe) in the blood and subsequent neurologic, cognitive, psychiatric, and behavioral dysfunction. Many patients report social isolation and decreased quality of life. Pegvaliase is an enzyme substitution therapy that reduces blood Phe levels in patients with PKU and is associated with a risk of hypersensitivity reactions. Objective To define the minimum acceptable benefit (MAB) of pegvaliase, i.e., the minimum probability of achieving a blood Phe level <360 μmol/L, which patients require to tolerate the risks of hypersensitivity associated with pegvaliase. Methods Adult, pegvaliase-naïve patients with blood Phe levels >600 μmol/L participated in a patient-preference web survey using two surveys: adapted swing-weighting and thresholding. Participants were asked to make ordinal choices between varying clinical benefit and severity levels for hypersensitivity. Disease effects and treatment satisfaction were also assessed. Results Among 45 participants, the mean (standard deviation) self-reported blood Phe level was 976.9 (429.9) μmol/L; only 28.8% reported satisfaction with their current treatment. Most (84.4%) indicated difficulty in following a PKU diet; 60% reported that the PKU diet was burdensome, and 58% reported feeling socially isolated. Most (≥69%) reported their MAB to be less than the expected clinical benefit provided by pegvaliase; the mean MAB was 22.7% and 34.4% in the swing-weighting and thresholding surveys, respectively. Conclusion Most participants felt the burden of PKU on their daily lives, were dissatisfied with current treatments, and were willing to accept the risks of hypersensitivity reactions to achieve recommended blood Phe levels with pegvaliase treatment.
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Affiliation(s)
- Sumitra SriBhashyam
- Patient Centered Research, Evidera, The Ark, 201 Talgarth Road, Hammersmith, London W6 8BJ, UK
| | - Kevin Marsh
- Patient Centered Research, Evidera, The Ark, 201 Talgarth Road, Hammersmith, London W6 8BJ, UK
| | - Adrian Quartel
- BioMarin Pharmaceutical Inc., 105 Digital Drive, Novato, CA 94949, USA
| | - Haoling H Weng
- BioMarin Pharmaceutical Inc., 105 Digital Drive, Novato, CA 94949, USA
| | - Ari Gershman
- BioMarin Pharmaceutical Inc., 105 Digital Drive, Novato, CA 94949, USA
| | - Nicola Longo
- Department of Pediatrics, Division of Medical Genetics, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Janet Thomas
- Department of Pediatrics, Section of Clinical Genetics and Metabolism, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Roberto Zori
- Department of Pediatrics, Division of Genetics and Metabolism, University of Florida, Gainesville, FL 32610, USA
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Zori R, Ahring K, Burton B, Pastores GM, Rutsch F, Jha A, Jurecki E, Rowell R, Harding C. Long-term comparative effectiveness of pegvaliase versus standard of care comparators in adults with phenylketonuria. Mol Genet Metab 2019; 128:92-101. [PMID: 31439512 PMCID: PMC9013411 DOI: 10.1016/j.ymgme.2019.07.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/30/2019] [Accepted: 07/30/2019] [Indexed: 12/20/2022]
Abstract
Phenylketonuria (PKU) is caused by phenylalanine hydroxylase (PAH) deficiency, resulting in high blood and brain Phenylalanine (Phe) concentrations that can lead to impaired brain development and function. Standard treatment involves a Phe-restricted diet alone or in conjunction with sapropterin dihydrochloride in responsive patients. The Food and Drug Administration approved pegvaliase enzyme substitution therapy for adults with blood Phe >600 μmol/L in the US. Recently, the European Commission also approved pegvaliase for treatment of PKU patients aged 16 years or older with blood Phe >600 μmol/L. The analyses presented below were conducted to provide comparative evidence on long-term treatment effectiveness of pegvaliase versus standard of care in adults with PKU. Adult patients (≥18 years) with baseline blood Phe >600 μmol/L who had enrolled in the pegvaliase phase 2 and phase 3 clinical trials were propensity score-matched to historical cohorts of patients treated with "sapropterin + diet" or with "diet alone". These cohorts were derived from the PKU Demographics, Outcome and Safety (PKUDOS) registry and compared for clinical outcomes including blood Phe concentration and natural intact protein intake after 1 and 2 years. Propensity scores were estimated using logistic regression with probability of treatment as outcome (i.e. pegvaliase, "sapropterin + diet", or "diet alone") and patient demographic and disease severity covariates as predictors. An additional analysis in adult PKU patients with baseline blood Phe ≤600 μmol/L comparing non-matched patient groups "sapropterin + diet" to "diet alone" using PKUDOS registry data only was also conducted. The analyses in patients with baseline blood Phe >600 μmol comparing pegvaliase with "sapropterin + diet" (N = 64 matched pairs) showed lower mean blood Phe concentrations after 1 and 2 years with pegvaliase (505 and 427 μmol/L) versus "sapropterin + diet" (807 and 891 μmol/L); mean natural intact protein intake after 1 and 2 years was 49 and 57 g/day respectively with pegvaliase versus 23 and 28 g/day with "sapropterin + diet". The analysis comparing pegvaliase with "diet alone" (N = 120 matched pairs) showed lower mean blood Phe at 1 and 2 years with pegvaliase (473 and 302 μmol/L) versus "diet alone" (1022 and 965 μmol/L); mean natural intact protein intake after 1 and 2 years was 47 and 57 g/day with pegvaliase and 27 and 22 g/day with "diet alone". Considerably more patients achieved blood Phe ≤600, ≤360, and ≤120 μmol/L and reductions from baseline of ≥20%, ≥30%, and ≥50% in blood Phe after 1 and 2 years of pegvaliase versus standard treatments. The analysis in patients with baseline blood Phe ≤600 μmol/L showed lower blood Phe after 1 and 2 years with "sapropterin + diet" (240 and 324 μmol/L) versus "diet alone" (580 and 549 μmol/L) and greater percentages of patients achieving blood Phe targets ≤600, ≤360, and ≤120 μmol/L and reductions from baseline of ≥20%, ≥30%, and ≥50% in blood Phe. These results support pegvaliase as the more effective treatment option to lower Phe levels in adults with PKU who have difficulty keeping blood Phe ≤600 μmol/L with "diet alone". For patients with blood Phe ≤600 μmol/L, adding sapropterin to dietary management is an appropriate treatment option, for those responsive to the treatment.
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Affiliation(s)
- Roberto Zori
- University of Florida Health, Gainesville, FL, USA.
| | - Kirsten Ahring
- Copenhagen University Hospital, Department of Paediatrics, PKU Clinic, Copenhagen, Denmark.
| | | | - Gregory M Pastores
- Mater Misericordiae University Hospital, University College Dublin, Dublin, Ireland.
| | - Frank Rutsch
- Münster University Children's Hospital, Department of General Pediatrics, Münster, Germany.
| | | | | | | | - Cary Harding
- Oregon Health & Science University, Portland, OR, USA.
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Hausmann O, Daha M, Longo N, Knol E, Müller I, Northrup H, Brockow K. Pegvaliase: Immunological profile and recommendations for the clinical management of hypersensitivity reactions in patients with phenylketonuria treated with this enzyme substitution therapy. Mol Genet Metab 2019; 128:84-91. [PMID: 31375398 DOI: 10.1016/j.ymgme.2019.05.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/13/2019] [Accepted: 05/13/2019] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To provide recommendations for managing hypersensitivity adverse events (HAEs) to an injectable enzyme substitution therapy (pegvaliase, a PEGylated phenylalanine ammonia lyase enzyme) in adult patients with phenylketonuria (PKU). METHODS Eight European academic immunology experts with a broad range of experience in hypersensitivity, anaphylaxis, and/or drug reactions, and two geneticists from the USA with pegvaliase experience convened for two advisory board meetings. Efficacy, safety, and immunological profile of pegvaliase were discussed with the objective of developing recommendations for the clinical management of HAEs associated with pegvaliase treatment. RESULTS Based on available immunogenicity data, it was concluded that pegvaliase induces a Type III hypersensitivity reaction, causing HAEs with peak event rates during induction/titration and a decline over time during maintenance therapy. The decline in HAEs with longer duration of therapy was considered to likely be driven by anti-drug antibody affinity maturation, reduced immune complex formation, and decreased complement activation over time. Immunology and PKU experts unanimously supported that the use of an induction, titration, and maintenance dosing regimen and implementation of several risk mitigation strategies contributed to the improvement of tolerability over time. Key risk mitigation strategies utilized in the Phase 3 clinical trials such as premedication with H1-receptor antagonists, allowance for a longer titration period after an HAE, patient education, and requirement to carry auto-injectable adrenaline (epinephrine) should be continued in clinical practice. A tool for administration of auto-injectable adrenaline in patients using pegvaliase was suggested. It was added that after the occurrence of a severe HAE a temporary dose reduction is more likely to improve tolerability than treatment interruption. CONCLUSIONS Overall, it was agreed that pegvaliase has a generally tolerable safety profile in adults with PKU. Importantly, the risk mitigation strategies utilized in the clinical trials were considered to support the continued use of key strategies for management in the commercial setting, such as a slow induction/titration dosing paradigm and premedication with H1-receptor antagonists. However, physicians and patients need to be aware of the risk of HAEs associated with pegvaliase; presence of a trained observer during early treatment may be beneficial in certain circumstances, and a requirement to carry auto-injectable adrenaline is recommended. Because pegvaliase offers the possibility to normalize diet, while maintaining blood phenylalanine within the recommended therapeutic range, safe use of this medication in the clinical setting is important. Ongoing monitoring of long-term clinical safety of patients on pegvaliase treatment in the commercial setting was recommended.
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Affiliation(s)
- Oliver Hausmann
- Adverse Drug Reactions, Analysis & Consulting (ADR-AC) GmbH, Bern, and Research Affiliate, Department of Rheumatology, Immunology and Allergology Inselspital, University of Bern, Switzerland
| | - Mohamed Daha
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
| | - Nicola Longo
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Edward Knol
- Department of Immunology and Dermatology, Department of Allergology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ingo Müller
- Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hope Northrup
- Department of Pediatrics, The McGovern Medical School, Houston, TX, USA
| | - Knut Brockow
- Department of Dermatology and Allergy, School of Medicine Technical University of Munich, Munich, Germany.
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Herenger Y, Maes E, François L, Pasco J, Bouchereau J, Pichard S, Ogier de Baulny H, Schiff M. Determining factors of the cognitive outcome in early treated PKU: A study of 39 pediatric patients. Mol Genet Metab Rep 2019; 20:100498. [PMID: 31384561 DOI: 10.1016/j.ymgmr.2019.100498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 07/19/2019] [Indexed: 11/23/2022] Open
Abstract
Phenylketonuria (PKU) is a disorder of phenylalanine metabolism, characterized by a neurotoxic phenylalanine (Phe) accumulation, and treatable with a life-long Phe-restricted diet. Though early and continuously treated PKU (ETPKU) patients exhibit normal IQ, their cognitive outcome remains suboptimal. In this longitudinal study, we aimed at assessing the determinants of IQ subscales and quality of metabolic control in ETPKU children. We collected blood Phe levels, numbers of blood samples for Phe determination, parents' socio-professional categories and school achievement data of 39 classical and moderate ETPKU patients who underwent two cognitive evaluations performed by the same neuropsychologist (at 6.5 and 10y of mean age). We then sought to evaluate the determinants of 1) the changes in their IQ between the two testings (delta IQ) and 2) the quality of metabolic control (evaluated by the median Phe levels during the year before the second test) with multivariate regression analysis. Though in the normal range, mean total IQ slightly decreased between the two evaluations, and we observed a better verbal than performance outcome. Modeling the determining factors of the delta IQ, we found a significant influence of the number of blood samples (β = 0.46, 95%CI = 0.13 to 0.79, p < 0.01) and the moderate type of PKU (β = 12.40, 95%CI = 3.69 to 21.11, p < 0.01) on verbal outcome. We failed to find any determining factors that would statistically influence metabolic control. In conclusion, ETPKU cognitive outcome is influenced by a network of metabolic and environmental factors, which is not reflected by the sole metabolic control.
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Canton M, Gall DL, Feillet F, Bonnemains C, Roy A. Neuropsychological Profile of Children with Early and Continuously Treated Phenylketonuria: Systematic Review and Future Approaches. J Int Neuropsychol Soc 2019; 25:624-43. [PMID: 31030702 DOI: 10.1017/S1355617719000146] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To provide a comprehensive systematic review of the literature by examining studies published on all cognitive aspects of children with early and continuously treated phenylketonuria (ECT-PKU) included in the databases Medline, PsycINFO, and PsycARTICLE. METHOD In addition to a classical approach, we summarized methodology and results of each study in order to discuss current theoretical and methodological issues. We also examined recent advances in biochemical markers and treatments of PKU, with implications for future research on metabolic control and its role as a determinant of neuropsychological outcome. RESULTS Consistent with previous reviews, the hypothesis of a specific and central executive impairment in children with ECT-PKU was suggested. However, findings are inconclusive regarding the nature of executive impairments as well as their specificity, impact on everyday life, persistence over time, and etiology. CONCLUSION Given the current state of the science, we suggest future directions for research that utilizes a developmental and integrative approach to examine the effects of recent advances in biochemical markers and treatment of PKU. (JINS, 2019, 25, 624-643).
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Feldmann R, Osterloh J, Onon S, Fromm J, Rutsch F, Weglage J. Neurocognitive functioning in adults with phenylketonuria: Report of a 10-year follow-up. Mol Genet Metab 2019; 126:246-249. [PMID: 30598390 DOI: 10.1016/j.ymgme.2018.12.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 12/15/2018] [Accepted: 12/24/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND The long-term prognosis of early treated phenylketonuria (PKU) is still under discussion. Aim of this controlled long-term study was to assess the neurological and neuropsychological outcome in adult patients with early-treated PKU. METHODS We investigated 35 patients with early-treated classical PKU aged 29 to 51 years (mean age 41 years) and 18 healthy controls matched for age and socioeconomic status. Patients and controls were assessed for their intelligence quotient (IQ), attention and information-processing abilities. Magnetic resonance imaging (MRI) of the brain was performed in all patients. Neuropsychological assessments and MRI were repeated at a five-year and a ten-year follow-up. RESULTS In the entire interval IQ, information processing and attention of patients and controls remained constant. At both follow-up assessment times the IQ scores were significantly lower in patients compared to controls. Older adult patients (> 42 years) showed poorer information processing and attention at both assessment times compared to young adult patients (< 42 years) and controls. IQ, information processing and attention showed no correlation to imaging results. IQ, however, was significantly correlated to blood phenylalanine (Phe) levels in patients´ childhood and adolescence, and Phe levels had been higher in the adolescent years of older adult patients. CONCLUSIONS Cognitive performance in adult patients with early-treated PKU does not seem to deteriorate in a ten-year interval. Neuropsychological assessment in adults with PKU revealed neurocognitive impairment particularly in older adult patients. This seems to refer to an early relaxation of diet that was recommended when the older patients were adolescents. Results indicate a benefit of dietary control during adolescence in PKU.
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Affiliation(s)
- R Feldmann
- University of Münster, Department of Pediatrics, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - J Osterloh
- University of Münster, Department of Pediatrics, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - S Onon
- University of Münster, Department of Pediatrics, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - J Fromm
- University of Münster, Department of Clinical Radiology, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - F Rutsch
- University of Münster, Department of Pediatrics, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - J Weglage
- University of Münster, Department of Pediatrics, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
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Burlina AP, Lachmann RH, Manara R, Cazzorla C, Celato A, van Spronsen FJ, Burlina A. The neurological and psychological phenotype of adult patients with early-treated phenylketonuria: A systematic review. J Inherit Metab Dis 2019; 42:209-219. [PMID: 30690773 DOI: 10.1002/jimd.12065] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 01/21/2019] [Indexed: 11/11/2022]
Abstract
Newborn screening for phenylketonuria (PKU) and early introduction of dietary therapy has been remarkably successful in preventing the severe neurological features of PKU, including mental retardation and epilepsy. However, concerns remain that long-term outcome is still suboptimal, particularly in adult patients who are no longer on strict phenylalanine-restricted diets. With our systematic literature review we aimed to describe the neurological phenotype of adults with early-treated phenylketonuria (ETPKU). The literature search covered the period from 1 January 1990 up to 16 April 2018, using the NLM MEDLINE controlled vocabulary. Of the 643 records initially identified, 83 were included in the analysis. The most commonly reported neurological signs were tremor and hyperreflexia. The overall quality of life (QoL) of ETPKU adults was good or comparable to control populations, and there was no evidence for a significant incidence of psychiatric disease or social difficulties. Neuroimaging revealed that brain abnormalities are present in ETPKU adults, but their clinical significance remains unclear. Generally, intelligence quotient (IQ) appears normal but specific deficits in neuropsychological and social functioning were reported in early-treated adults compared with healthy individuals. However, accurately defining the prevalence of these deficits is complicated by the lack of standardized neuropsychological tests. Future research should employ standardized neurological, neuropsychological, and neuroimaging protocols, and consider other techniques such as advanced imaging analyses and the recently validated PKU-specific QoL questionnaire, to precisely define the nature of the impairments within the adult ETPKU population and how these relate to metabolic control throughout life.
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Affiliation(s)
| | - Robin H Lachmann
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Renzo Manara
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Chiara Cazzorla
- Division of Inborn Metabolic Diseases, Department of Paediatrics, University Hospital, Padua, Italy
| | - Andrea Celato
- Division of Inborn Metabolic Diseases, Department of Paediatrics, University Hospital, Padua, Italy
| | - Francjan J van Spronsen
- Division of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center of Groningen, University of Groningen, Groningen, The Netherlands
| | - Alberto Burlina
- Division of Inborn Metabolic Diseases, Department of Paediatrics, University Hospital, Padua, Italy
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Eissa HA, Abdallah ZY, Khalil WKB, Ibrahim WA, Booles HF, Hassanane MM. Effect of natural PAL-enzyme on the quality of egg white and mushroom flour and study its impact on the expression of PKU related genes and phenylalanine reduction in mice fed on. J Genet Eng Biotechnol 2019; 15:443-451. [PMID: 30647685 PMCID: PMC6296627 DOI: 10.1016/j.jgeb.2017.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Revised: 04/16/2017] [Accepted: 07/27/2017] [Indexed: 11/30/2022]
Abstract
PKU patients react to therapy with a low phenylalanine diet, but adherence to this diet is troublesome, subsequently the expansion of alternative ways is demand. Phenylalanine ammonia lyase (PAL) is one of this ways, which converts phenylalanine to harmless metabolites; trans-cinnamic acid and ammonia. In the current study, the extraction of PAL enzyme was used to investigate the efficiency for production of functional PKU egg white and mushroom flour with good quality by evaluation of colour characteristics, determination of phenylalanine concentrations and genetic materials expression of PKU related genes and DNA damage. Results indicated that the PAL enzyme treated of egg white and mushroom flour was stable colour and the calculated reduction per cent in phenylalanine concentration from female mice fed on untreated and PAL–treated samples was 22.77% in egg white and 31.37% in mushroom flour. Also, the results revealed that female mice fed on diet contained treated egg white exhibited low expression levels of PKU exons (3, 6, 7, 11, and 12) and low DNA damage which were similar to those in control mice.
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Affiliation(s)
- Hesham A Eissa
- Food Technology Department, 33 El boohoos, National Research Centre, 12622 Cairo, Egypt
| | - Zeinab Y Abdallah
- Biochemical Genetics Department, 33 El boohoos, National Research Centre, 12622 Cairo, Egypt
| | - Wagdy K B Khalil
- Cell Biology Department, 33 El boohoos, National Research Centre, 12622 Cairo, Egypt
| | - Wafaa A Ibrahim
- Food Technology Department, 33 El boohoos, National Research Centre, 12622 Cairo, Egypt
| | - Hoda F Booles
- Cell Biology Department, 33 El boohoos, National Research Centre, 12622 Cairo, Egypt
| | - Mahrousa M Hassanane
- Cell Biology Department, 33 El boohoos, National Research Centre, 12622 Cairo, Egypt
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Ashe K, Kelso W, Farrand S, Panetta J, Fazio T, De Jong G, Walterfang M. Psychiatric and Cognitive Aspects of Phenylketonuria: The Limitations of Diet and Promise of New Treatments. Front Psychiatry 2019; 10:561. [PMID: 31551819 PMCID: PMC6748028 DOI: 10.3389/fpsyt.2019.00561] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 07/17/2019] [Indexed: 12/30/2022] Open
Abstract
Phenylketonuria (PKU) is a recessive disorder of phenylalanine metabolism due to mutations in the gene for phenylalanine hydroxylase (PAH). Reduced PAH activity results in significant hyperphenylalaninemia, which leads to alterations in cerebral myelin and protein synthesis, as well as reduced levels of serotonin, dopamine, and noradrenaline in the brain. When untreated, brain development is grossly disrupted and significant intellectual impairment and behavioral disturbance occur. The advent of neonatal heel prick screening has allowed for diagnosis at birth, and the institution of a phenylalanine restricted diet. Dietary treatment, particularly when maintained across neurodevelopment and well into adulthood, has resulted in markedly improved outcomes at a cognitive and psychiatric level for individuals with PKU. However, few individuals can maintain full dietary control lifelong, and even with good control, an elevated risk remains of-in particular-mood, anxiety, and attentional disorders across the lifespan. Increasingly, dietary recommendations focus on maintaining continuous dietary treatment lifelong to optimize psychiatric and cognitive outcomes, although the effect of long-term protein restricted diets on brain function remains unknown. While psychiatric illness is very common in adult PKU populations, very little data exist to guide clinicians on optimal treatment. The advent of new treatments that do not require restrictive dietary management, such as the enzyme therapy Pegvaliase, holds the promise of allowing patients a relatively normal diet alongside optimized mental health and cognitive functioning.
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Affiliation(s)
- Killian Ashe
- Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Wendy Kelso
- Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Sarah Farrand
- Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Julie Panetta
- Statewide Adult Metabolic Service, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Tim Fazio
- Statewide Adult Metabolic Service, Royal Melbourne Hospital, Melbourne, VIC, Australia.,Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Gerard De Jong
- Statewide Adult Metabolic Service, Royal Melbourne Hospital, Melbourne, VIC, Australia.,Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Mark Walterfang
- Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia.,Melbourne Neuropsychiatry Centre, University of Melbourne and North-Western Mental Health, Melbourne, VIC, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia
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44
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Gupta S, Lau K, Harding CO, Shepherd G, Boyer R, Atkinson JP, Knight V, Olbertz J, Larimore K, Gu Z, Li M, Rosen O, Zoog SJ, Weng HH, Schweighardt B. Association of immune response with efficacy and safety outcomes in adults with phenylketonuria administered pegvaliase in phase 3 clinical trials. EBioMedicine 2018; 37:366-373. [PMID: 30366815 PMCID: PMC6286649 DOI: 10.1016/j.ebiom.2018.10.038] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 10/12/2018] [Accepted: 10/12/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND This study assessed the immunogenicity of pegvaliase (recombinant Anabaena variabilis phenylalanine [Phe] ammonia lyase [PAL] conjugated with polyethylene glycol [PEG]) treatment in adults with phenylketonuria (PKU) and its impact on safety and efficacy. METHODS Immunogenicity was assessed during induction, upward titration, and maintenance dosing regimens in adults with PKU (n = 261). Total antidrug antibodies (ADA), neutralizing antibodies, immunoglobulin (Ig) M and IgG antibodies against PAL and PEG, IgG and IgM circulating immune complex (CIC) levels, complement components 3 and 4 (C3/C4), plasma Phe, and safety were assessed at baseline and throughout the study. Pegvaliase-specific IgE levels were measured in patients after hypersensitivity adverse events (HAE). FINDINGS All patients developed ADA against PAL, peaking by 6 months and then stabilizing. Most developed transient antibody responses against PEG, peaking by 3 months, then returning to baseline by 9 months. Binding of ADA to pegvaliase led to CIC formation and complement activation, which were highest during early treatment. Blood Phe decreased over time as CIC levels and complement activation declined and pegvaliase dosage increased. HAEs were most frequent during early treatment and declined over time. No patient with acute systemic hypersensitivity events tested positive for pegvaliase-specific IgE near the time of the event. Laboratory evidence was consistent with immune complex-mediated type III hypersensitivity. No evidence of pegvaliase-associated IC-mediated end organ damage was noted. INTERPRETATION Despite a universal ADA response post-pegvaliase administration, adult patients with PKU achieved substantial and sustained blood Phe reductions with a manageable safety profile. FUND: BioMarin Pharmaceutical Inc.
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Affiliation(s)
- Soumi Gupta
- BioMarin Pharmaceutical Inc., 105 Digital Dr, Novato, CA 94949, United States.
| | - Kelly Lau
- BioMarin Pharmaceutical Inc., 105 Digital Dr, Novato, CA 94949, United States
| | - Cary O Harding
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, United States
| | - Gillian Shepherd
- Weill Medical College of Cornell University, 47 East 91st St, New York, NY 10128, United States
| | - Ryan Boyer
- BioMarin Pharmaceutical Inc., 105 Digital Dr, Novato, CA 94949, United States
| | - John P Atkinson
- Washington University School of Medicine, Campus Box 8045, 660 S. Euclid Ave, St. Louis, MO 63110, United States
| | - Vijaya Knight
- National Jewish Health Advanced Diagnostic Laboratories, 1400 Jackson St, Denver, CO 80206, United States
| | - Joy Olbertz
- BioMarin Pharmaceutical Inc., 105 Digital Dr, Novato, CA 94949, United States
| | - Kevin Larimore
- BioMarin Pharmaceutical Inc., 105 Digital Dr, Novato, CA 94949, United States
| | - Zhonghu Gu
- BioMarin Pharmaceutical Inc., 105 Digital Dr, Novato, CA 94949, United States
| | - Mingjin Li
- BioMarin Pharmaceutical Inc., 105 Digital Dr, Novato, CA 94949, United States
| | - Orli Rosen
- BioMarin Pharmaceutical Inc., 105 Digital Dr, Novato, CA 94949, United States
| | - Stephen J Zoog
- BioMarin Pharmaceutical Inc., 105 Digital Dr, Novato, CA 94949, United States
| | - Haoling H Weng
- BioMarin Pharmaceutical Inc., 105 Digital Dr, Novato, CA 94949, United States
| | - Becky Schweighardt
- BioMarin Pharmaceutical Inc., 105 Digital Dr, Novato, CA 94949, United States
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45
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Lepping RJ, Honea RA, Martin LE, Liao K, Choi IY, Lee P, Papa VB, Brooks WM, Shaddy DJ, Carlson SE, Colombo J, Gustafson KM. Long-chain polyunsaturated fatty acid supplementation in the first year of life affects brain function, structure, and metabolism at age nine years. Dev Psychobiol 2018; 61:5-16. [PMID: 30311214 DOI: 10.1002/dev.21780] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 08/08/2018] [Accepted: 08/15/2018] [Indexed: 01/02/2023]
Abstract
The present study sought to determine whether supplementation of long-chain polyunsaturated fatty acids (LCPUFA) during the first year of life influenced brain function, structure, and metabolism at 9 years of age. Newborns were randomly assigned to consume formula containing either no LCPUFA (control) or formula with 0.64% of total fatty acids as arachidonic acid (ARA; 20:4n6) and variable amounts of docosahexaenoic acid (DHA; 22:6n3) (0.32%, 0.64%, or 0.96% of total fatty acids) from birth to 12 months. At age 9 years (±0.6), 42 children enrolled in a follow-up multimodal magnetic resonance imaging (MRI) study including functional (fMRI, Flanker task), resting state (rsMRI), anatomic, and proton magnetic resonance spectroscopy (1 H MRS). fMRI analysis using the Flanker task found that trials requiring greater inhibition elicited greater brain activation in LCPUFA-supplemented children in anterior cingulate cortex (ACC) and parietal regions. rsMRI analysis showed that children in the 0.64% group exhibited greater connectivity between prefrontal and parietal regions compared to all other groups. In addition, voxel-based analysis (VBM) revealed that the 0.32% and 0.64% groups had greater white matter volume in ACC and parietal regions compared to controls and the 0.96% group. Finally, 1 H MRS data analysis identified that N-acetylaspartate (NAA) and myo-inositol (mI) were higher in LCPUFA groups compared to the control group. LCPUFA supplementation during infancy has lasting effects on brain structure, function, and neurochemical concentrations in regions associated with attention (parietal) and inhibition (ACC), as well as neurochemicals associated with neuronal integrity (NAA) and brain cell signaling (mI).
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Affiliation(s)
- Rebecca J Lepping
- Hoglund Brain Imaging Center, University of Kansas Medical Center (KUMC), Kansas City, Kansas
| | - Robyn A Honea
- Department of Neurology, University of Kansas Medical Center (KUMC), Kansas City, Kansas
| | - Laura E Martin
- Hoglund Brain Imaging Center, University of Kansas Medical Center (KUMC), Kansas City, Kansas.,Department of Preventive Medicine and Public Health, University of Kansas Medical Center (KUMC), Kansas City, Kansas
| | - Ke Liao
- Hoglund Brain Imaging Center, University of Kansas Medical Center (KUMC), Kansas City, Kansas
| | - In-Young Choi
- Hoglund Brain Imaging Center, University of Kansas Medical Center (KUMC), Kansas City, Kansas.,Department of Neurology, University of Kansas Medical Center (KUMC), Kansas City, Kansas.,Department of Molecular & Integrative Physiology, University of Kansas Medical Center (KUMC), Kansas City, Kansas
| | - Phil Lee
- Hoglund Brain Imaging Center, University of Kansas Medical Center (KUMC), Kansas City, Kansas.,Department of Molecular & Integrative Physiology, University of Kansas Medical Center (KUMC), Kansas City, Kansas
| | - Vlad B Papa
- Hoglund Brain Imaging Center, University of Kansas Medical Center (KUMC), Kansas City, Kansas
| | - William M Brooks
- Hoglund Brain Imaging Center, University of Kansas Medical Center (KUMC), Kansas City, Kansas.,Department of Neurology, University of Kansas Medical Center (KUMC), Kansas City, Kansas
| | - D Jill Shaddy
- Department of Dietetics and Nutrition, University of Kansas Medical Center (KUMC), Kansas City, Kansas
| | - Susan E Carlson
- Department of Dietetics and Nutrition, University of Kansas Medical Center (KUMC), Kansas City, Kansas
| | - John Colombo
- Schiefelbusch Institute for Life Span Studies, Department of Psychology, University of Kansas, Lawrence, Kansas
| | - Kathleen M Gustafson
- Hoglund Brain Imaging Center, University of Kansas Medical Center (KUMC), Kansas City, Kansas.,Department of Neurology, University of Kansas Medical Center (KUMC), Kansas City, Kansas
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Bartus A, Palasti F, Juhasz E, Kiss E, Simonova E, Sumanszki C, Reismann P. The influence of blood phenylalanine levels on neurocognitive function in adult PKU patients. Metab Brain Dis 2018; 33:1609-1615. [PMID: 29948654 DOI: 10.1007/s11011-018-0267-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 06/06/2018] [Indexed: 10/14/2022]
Abstract
It is well known that hyperphenylalaninemia caused by phenylketonuria (PKU) negatively influences cognitive performance. Several tests have been used to study these functions. Until now, no universal, optimal tool has been developed for detecting PKU-caused brain dysfunctions. Using computerized neuropsychological tests during daily routine would be helpful for screening subclinical brain deficits in adult PKU patients. In a monocentric, cross-sectional study, adult patients with PKU (n = 46; median age = 29.5 years; female/male ratio = 21/25) were tested with the computerized Cambridge Cognition (CANTAB) test measuring neurocognitive functions. Patients were divided into two groups: The "on diet" group included patients whose blood Phe-level was under 600 μmol/l (n = 20), and the "loose diet" group included patients whose blood Phe-level was above 600 μmol/l (n = 26) at the examination time. The results of the PKU-affected individuals were compared with a healthy control group (n = 31; median age = 25 years; female/male ratio = 11/20). Compared with the control group, PKU patients had significantly worse test results in memory, problem-solving skills, and strategy. However, there were no significant differences in response speed or initial thinking time. There was no correlation between the blood Phe-level, tyrosine (Tyr)-level or Phe/Tyr ratio and the different cognitive test results. There were no significant differences in test results between the two PKU subgroups. Several cognitive functions measured by CANTAB are negatively influenced by hyperphenylalaninemia in adult PKU patients. However, response speed and initial thinking time were not impaired as seriously as other functions. Patients with lower Phe-levels failed to achieve better test results than patients whose Phe-levels were notably elevated.
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Affiliation(s)
- A Bartus
- 2nd Department of Internal Medicine, Semmelweis University, Szentkirályi Street 46, Budapest, H-1088, Hungary
| | - F Palasti
- 2nd Department of Internal Medicine, Semmelweis University, Szentkirályi Street 46, Budapest, H-1088, Hungary
| | - E Juhasz
- 2nd Department of Internal Medicine, Semmelweis University, Szentkirályi Street 46, Budapest, H-1088, Hungary
| | - E Kiss
- 1st Department of Pediatrics, Semmelweis University, Bókay János u. 53-54, Budapest, H-1083, Hungary
| | - E Simonova
- 1st Department of Pediatrics, Semmelweis University, Bókay János u. 53-54, Budapest, H-1083, Hungary
| | - Cs Sumanszki
- 2nd Department of Internal Medicine, Semmelweis University, Szentkirályi Street 46, Budapest, H-1088, Hungary
| | - P Reismann
- 2nd Department of Internal Medicine, Semmelweis University, Szentkirályi Street 46, Budapest, H-1088, Hungary.
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Thomas J, Levy H, Amato S, Vockley J, Zori R, Dimmock D, Harding CO, Bilder DA, Weng HH, Olbertz J, Merilainen M, Jiang J, Larimore K, Gupta S, Gu Z, Northrup H. Pegvaliase for the treatment of phenylketonuria: Results of a long-term phase 3 clinical trial program (PRISM). Mol Genet Metab 2018; 124:27-38. [PMID: 29653686 DOI: 10.1016/j.ymgme.2018.03.006] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 03/15/2018] [Accepted: 03/15/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Phenylketonuria (PKU) is caused by phenylalanine hydroxylase (PAH) deficiency that results in phenylalanine (Phe) accumulation. Pegvaliase, PEGylated recombinant Anabaena variabilis phenylalanine ammonia lyase (PAL), converts Phe to trans-cinnamic acid and ammonia, and is a potential enzyme substitution therapy to lower blood Phe in adults with PKU. METHODS Two Phase 3 studies, PRISM-1 and PRISM-2, evaluated the efficacy and safety of pegvaliase treatment using an induction, titration, and maintenance dosing regimen in adults with PKU. In PRISM-1, pegvaliase-naïve participants with blood Phe >600 μmol/L were randomized 1:1 to a maintenance dose of 20 mg/day or 40 mg/day of pegvaliase. Participants in PRISM-1 continued pegvaliase treatment in PRISM-2, a 4-part clinical trial that includes an ongoing, open-label, long-term extension study of pegvaliase doses of 5 mg/day to 60 mg/day. RESULTS Of 261 participants who received pegvaliase treatment, 72.0% and 32.6% reached ≥12 months and ≥ 24 months of study treatment, respectively, and 65% are still actively receiving treatment. Mean (SD) blood Phe was 1232.7 (386.4) μmol/L at baseline, 564.5 (531.2) μmol/L at 12 months, and 311.4 (427) μmol/L at 24 months, a decrease from baseline of 51.1% and 68.7%, respectively. Within 24 months, 68.4% of participants achieved blood Phe ≤600 μmol/L, 60.7% of participants achieved blood Phe ≤360 μmol/L, below the upper limit recommended in the American College of Medical Genetics and Genomics PKU management guidelines, and 51.2% achieved blood Phe ≤120 μmol/L, below the upper limit of normal in the unaffected population. Improvements in neuropsychiatric outcomes were associated with reductions in blood Phe and were sustained with long-term pegvaliase treatment. Adverse events (AEs) were more frequent in the first 6 months of exposure (early treatment phase) than after 6 months of exposure (late treatment phase); 99% of AEs were mild or moderate in severity and 96% resolved without dose interruption or reduction. The most common AEs were arthralgia (70.5%), injection-site reaction (62.1%), injection-site erythema (47.9%), and headache (47.1%). Acute systemic hypersensitivity events consistent with clinical National Institute of Allergy and Infectious Diseases and the Food Allergy and Anaphylaxis Network anaphylaxis criteria were observed in 12 participants (17 events); of these, 6 participants remained on treatment. Acute systemic hypersensitivity events including potential events of anaphylaxis were not associated with immunoglobulin E, and all events resolved without sequelae. CONCLUSION Results from the PRISM Phase 3 program support the efficacy of pegvaliase for the treatment of adults with PKU, with a manageable safety profile in most participants. The PRISM-2 extension study will continue to assess the long-term effects of pegvaliase treatment.
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Affiliation(s)
- Janet Thomas
- Department of Pediatrics, Section of Clinical Genetics and Metabolism, University of Colorado School of Medicine, Aurora, CO 80045, USA.
| | - Harvey Levy
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA 02115, USA.
| | - Stephen Amato
- Pediatric Genetics and Metabolism, University of Kentucky, Lexington, KY 40506, USA.
| | - Jerry Vockley
- Department of Pediatrics, Division of Medical Genetics, University of Pittsburgh and Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA.
| | - Roberto Zori
- Genetics and Metabolism, University of Florida, Gainesville, FL 32610, USA.
| | - David Dimmock
- Rady Children's Institute for Genomic Medicine, San Diego, CA 92123, USA.
| | - Cary O Harding
- Molecular and Medical Genetics, Oregon Health & Science University, Portland, OR 97239, USA.
| | | | - Haoling H Weng
- Research and Development, BioMarin Pharmaceutical Inc., Novato, CA 94949, USA.
| | - Joy Olbertz
- Research and Development, BioMarin Pharmaceutical Inc., Novato, CA 94949, USA.
| | - Markus Merilainen
- Research and Development, BioMarin Pharmaceutical Inc., Novato, CA 94949, USA.
| | - Joy Jiang
- Research and Development, BioMarin Pharmaceutical Inc., Novato, CA 94949, USA.
| | - Kevin Larimore
- Research and Development, BioMarin Pharmaceutical Inc., Novato, CA 94949, USA.
| | - Soumi Gupta
- Research and Development, BioMarin Pharmaceutical Inc., Novato, CA 94949, USA.
| | - Zhonghua Gu
- Research and Development, BioMarin Pharmaceutical Inc., Novato, CA 94949, USA.
| | - Hope Northrup
- Department of Pediatrics, Division of Medical Genetics, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA.
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De Felice S, Romani C, Geberhiwot T, MacDonald A, Palermo L. Language processing and executive functions in early treated adults with phenylketonuria (PKU). Cogn Neuropsychol 2018; 35:148-170. [DOI: 10.1080/02643294.2017.1422709] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Sara De Felice
- School of Life and Health Sciences, Aston University, Birmingham, UK
- IMD Department, Queen Elizabeth Hospital, Birmingham, UK
| | - Cristina Romani
- School of Life and Health Sciences, Aston University, Birmingham, UK
| | | | - Anita MacDonald
- Dietetic Department, Birmingham Children’s Hospital, Birmingham, UK
| | - Liana Palermo
- School of Life and Health Sciences, Aston University, Birmingham, UK
- IMD Department, Queen Elizabeth Hospital, Birmingham, UK
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
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49
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Dimer NW, Ferreira BK, Agostini JF, Gomes ML, Kist LW, Malgarin F, Carvalho-Silva M, Gomes LM, Rebelo J, Frederico MJS, Silva FRMB, Rico EP, Bogo MR, Streck EL, Ferreira GC, Schuck PF. Brain bioenergetics in rats with acute hyperphenylalaninemia. Neurochem Int 2018; 117:188-203. [PMID: 29454001 DOI: 10.1016/j.neuint.2018.01.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 12/21/2017] [Accepted: 01/03/2018] [Indexed: 12/15/2022]
Abstract
Phenylketonuria (PKU) is a disorder of phenylalanine (Phe) metabolism caused by deficient phenylalanine hydroxylase (PAH) activity. The deficiency results in increased levels of Phe and its metabolites in fluids and tissues of patients. PKU patients present neurological signs and symptoms including hypomyelination and intellectual deficit. This study assessed brain bioenergetics at 1 h after acute Phe administration to induce hyperphenylalaninemia (HPA) in rats. Wistar rats were randomized in two groups: HPA animals received a single subcutaneous administration of Phe (5.2 μmol/g) plus p-Cl-Phe (PAH inhibitor) (0.9 μmol/g); control animals received a single injection of 0.9% NaCl. In cerebral cortex, HPA group showed lower mitochondrial mass, lower glycogen levels, as well as lower activities of complexes I-III and IV, ATP synthase and citrate synthase. Higher levels of free Pi and phospho-AMPK, and higher activities of LDH, α-ketoglutarate dehydrogenase and isocitrate dehydrogenase were also reported in cerebral cortex of HPA animals. In striatum, HPA animals had higher LDH (pyruvate to lactate) and isocitrate dehydrogenase activities, and lower activities of α-ketoglutarate dehydrogenase and complex IV, as well as lower phospho-AMPK immunocontent. In hippocampus, HPA rats had higher mRNA expression for MFN1 and higher activities of α-ketoglutarate dehydrogenase and isocitrate dehydrogenase, but decreased activities of pyruvate dehydrogenase and complexes I and IV. In conclusion, our data demonstrated impaired bioenergetics in cerebral cortex, striatum and hippocampus of HPA rats.
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Affiliation(s)
- Nádia Weber Dimer
- Laboratório de Erros Inatos do Metabolismo, Unidade Acadêmica de Ciências da Saúde, Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil
| | - Bruna Klippel Ferreira
- Laboratório de Erros Inatos do Metabolismo, Unidade Acadêmica de Ciências da Saúde, Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil; Laboratório de Neuroenergética e Erros Inatos do Metabolismo, Instituto de Bioquímica Médica Leopoldo de Meis, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Jotele Fontana Agostini
- Laboratório de Erros Inatos do Metabolismo, Unidade Acadêmica de Ciências da Saúde, Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil
| | - Maria Luiza Gomes
- Laboratório de Erros Inatos do Metabolismo, Unidade Acadêmica de Ciências da Saúde, Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil
| | - Luiza Wilges Kist
- Laboratório de Biologia Genômica e Molecular, Faculdade de Biociências, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Fernanda Malgarin
- Laboratório de Erros Inatos do Metabolismo, Unidade Acadêmica de Ciências da Saúde, Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil
| | - Milena Carvalho-Silva
- Laboratório de Bioenergética, Unidade Acadêmica de Ciências da Saúde, Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil
| | - Lara Mezari Gomes
- Laboratório de Bioenergética, Unidade Acadêmica de Ciências da Saúde, Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil
| | - Joyce Rebelo
- Laboratório de Bioenergética, Unidade Acadêmica de Ciências da Saúde, Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil
| | - Marisa Jádna Silva Frederico
- Laboratório de Hormônios e Transdução de Sinais, Departamento de Bioquímica, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Fátima Regina Mena Barreto Silva
- Laboratório de Hormônios e Transdução de Sinais, Departamento de Bioquímica, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Eduardo Pacheco Rico
- Laboratório de Sinalização Neural e Psicofarmacologia, Unidade Acadêmica de Ciências da Saúde, Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil
| | - Mauricio Reis Bogo
- Laboratório de Biologia Genômica e Molecular, Faculdade de Biociências, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Emilio Luiz Streck
- Laboratório de Bioenergética, Unidade Acadêmica de Ciências da Saúde, Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil
| | - Gustavo Costa Ferreira
- Laboratório de Neuroenergética e Erros Inatos do Metabolismo, Instituto de Bioquímica Médica Leopoldo de Meis, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Patrícia Fernanda Schuck
- Laboratório de Erros Inatos do Metabolismo, Unidade Acadêmica de Ciências da Saúde, Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil.
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50
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Manti F, Nardecchia F, Paci S, Chiarotti F, Carducci C, Carducci C, Dalmazzone S, Cefalo G, Salvatici E, Banderali G, Leuzzi V. Predictability and inconsistencies in the cognitive outcome of early treated PKU patients. J Inherit Metab Dis 2017; 40:793-799. [PMID: 28836033 DOI: 10.1007/s10545-017-0082-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 08/03/2017] [Accepted: 08/03/2017] [Indexed: 01/30/2023]
Abstract
Long-term cognitive outcome and treatment of adult early treated (ET)PKU patients is a main issue in PKU research. We questioned whether the intellectual development of ETPKU patients is stable and to what extent its variation may be predicted by the quality of metabolic control. The aims of the present longitudinal retrospective study were to assess in young adult ETPKU patients: i) the relationship between IQ and metabolic control during the first two decades of life; and ii) the intra- and interindividual variability in the developmental trajectory which cannot be predicted by the disease's biomarkers. We collected biochemical data from 65 ETPKU patients (diagnostic blood Phe > 360 μmol/l) who were assessed twice for IQ (Wechsler Intelligence Scale) during their lifetime (mean age: 10.2 and 19.6 years, respectively). Results show that in ETPKU patients IQ over the second decade of life remained stable in about half of the patients (51%); while the rest experienced a gain (7 to 15 points) or loss (7 to 28 points) in IQ scores (23 and 26% respectively) whatever the quality of metabolic control was. The main factor affecting the second IQ was the value of the first IQ (p < 0.000) whose effect overruled that of the markers of metabolic control. Looking at the developmental trajectory of our ETPKU patients, the present study disclosed a remarkable interindividual variability in their cognitive outcome and also an inconsistent linkage between cognitive performances and biochemical control, thus supporting the hypothesis of an individual resilience or vulnerability to Phe in young adult ETPKU.
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Affiliation(s)
- Filippo Manti
- Department of Pediatrics and Child Neurology and Psychiatry, Sapienza University of Rome, Via dei Sabelli 108, 00185, Rome, Italy
| | - Francesca Nardecchia
- Department of Pediatrics and Child Neurology and Psychiatry, Sapienza University of Rome, Via dei Sabelli 108, 00185, Rome, Italy
| | - Sabrina Paci
- Department of Pediatrics, University of Milan, San Paolo Hospital, Santi Paolo e Carlo ASST, Via Antonio Di Rudinì 8, 20142, Milan, Italy
| | - Flavia Chiarotti
- Department of Cell Biology and Neuroscience, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161, Rome, Italy
| | - Claudia Carducci
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Carla Carducci
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Silvia Dalmazzone
- Department of Pediatrics, University of Milan, San Paolo Hospital, Santi Paolo e Carlo ASST, Via Antonio Di Rudinì 8, 20142, Milan, Italy
| | - Graziella Cefalo
- Department of Pediatrics, University of Milan, San Paolo Hospital, Santi Paolo e Carlo ASST, Via Antonio Di Rudinì 8, 20142, Milan, Italy
| | - Elisabetta Salvatici
- Department of Pediatrics, University of Milan, San Paolo Hospital, Santi Paolo e Carlo ASST, Via Antonio Di Rudinì 8, 20142, Milan, Italy
| | - Giuseppe Banderali
- Department of Pediatrics, University of Milan, San Paolo Hospital, Santi Paolo e Carlo ASST, Via Antonio Di Rudinì 8, 20142, Milan, Italy
| | - Vincenzo Leuzzi
- Department of Pediatrics and Child Neurology and Psychiatry, Sapienza University of Rome, Via dei Sabelli 108, 00185, Rome, Italy.
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