1
|
Duff C, Alexander IE, Baruteau J. Gene therapy for urea cycle defects: An update from historical perspectives to future prospects. J Inherit Metab Dis 2024; 47:50-62. [PMID: 37026568 PMCID: PMC10953416 DOI: 10.1002/jimd.12609] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 01/19/2023] [Revised: 03/31/2023] [Accepted: 04/04/2023] [Indexed: 04/08/2023]
Abstract
Urea cycle defects (UCDs) are severe inherited metabolic diseases with high unmet needs which present a permanent risk of hyperammonaemic decompensation and subsequent acute death or neurological sequelae, when treated with conventional dietetic and medical therapies. Liver transplantation is currently the only curative option, but has the potential to be supplanted by highly effective gene therapy interventions without the attendant need for life-long immunosuppression or limitations imposed by donor liver supply. Over the last three decades, pioneering genetic technologies have been explored to circumvent the consequences of UCDs, improve quality of life and long-term outcomes: adenoviral vectors, adeno-associated viral vectors, gene editing, genome integration and non-viral technology with messenger RNA. In this review, we present a summarised view of this historical path, which includes some seminal milestones of the gene therapy's epic. We provide an update about the state of the art of gene therapy technologies for UCDs and the current advantages and pitfalls driving future directions for research and development.
Collapse
Affiliation(s)
- Claire Duff
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
| | - Ian E. Alexander
- Gene Therapy Research Unit, Children's Medical Research Institute, Faculty of Medicine and HealthThe University of Sydney and Sydney Children's Hospitals NetworkWestmeadNew South WalesAustralia
- Discipline of Child and Adolescent HealthThe University of SydneyWestmeadNew South WalesAustralia
| | - Julien Baruteau
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
- National Institute of Health Research Great Ormond Street Biomedical Research CentreLondonUK
- Metabolic Medicine DepartmentGreat Ormond Street Hospital for Children NHS Foundation TrustLondonUK
| |
Collapse
|
2
|
Rezvani M, Campbell KM, Prada CE, Peters AL. Early allograft dysfunction in a pediatric liver allograft with an occult pathogenic mutation in the urea cycle. Am J Transplant 2023; 23:673-675. [PMID: 36870389 DOI: 10.1016/j.ajt.2023.02.027] [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: 11/28/2022] [Revised: 02/17/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023]
Abstract
Liver transplantation risks transferring a genetic defect in metabolic pathways, including the urea cycle. We present a case of pediatric liver transplantation complicated by metabolic crisis and early allograft dysfunction (EAD) in a previously healthy unrelated deceased donor. Allograft function improved with supportive care, and retransplantation was avoided. Because hyperammonemia suggested an enzymatic defect in the allograft, genetic testing from donor-derived deoxyribonucleic acid revealed a heterozygous mutation in the ASL gene, which encodes the urea cycle enzyme argininosuccinate lyase. Homozygous ASL mutations precipitate metabolic crises during fasting or postoperative states, whereas heterozygous carriers retain sufficient enzyme activity and are asymptomatic. In the described case, postoperative ischemia/reperfusion injury created a metabolic demand that exceeded the enzymatic capacity of the allograft. To our knowledge, this is the first report of an acquired argininosuccinate lyase deficiency by liver transplantation and underscores the importance of considering occult metabolic variants in the allograft during EAD.
Collapse
Affiliation(s)
- Milad Rezvani
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Pediatric Gastroenterology, Nephrology and Metabolic Medicine, Berlin, Germany; Berlin Institute of Health, Berlin, Germany
| | - Kathleen M Campbell
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Carlos E Prada
- Division of Genetics, Genomics and Metabolism, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Anna L Peters
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
| |
Collapse
|
3
|
De Bruyne P, Verloo P, Van Hove JLK, de Hemptinne B, Vande Velde S, Van Winckel M, Van Biervliet S, De Bruyne R. Successful liver transplantation in hyperornithinemia-hyperammonemia-homocitrullinuria syndrome: Case report. Pediatr Transplant 2021; 25:e13943. [PMID: 33314525 DOI: 10.1111/petr.13943] [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: 04/19/2020] [Revised: 10/25/2020] [Accepted: 10/26/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND HHH syndrome is a rare autosomal recessive disorder of the urea cycle, caused by a deficient mitochondrial ornithine transporter. We report the first successful liver transplantation in HHH syndrome performed in a seven-year-old boy. The patient presented at 4 weeks of age with hyperammonemic coma. The plasma amino acid profile was suggestive of HHH syndrome, and the diagnosis was confirmed when sequencing of the SLC25A15 gene identified two mutations p.R275Q and p.A76D. Although immediate intervention resulted in normalization of plasma ammonia levels within 24 hours, he developed cerebral edema, coma, convulsions, and subsequent neurological sequelae. Metabolic control was difficult requiring severe protein restriction and continued treatment with sodium benzoate and L-arginine. Despite substantial developmental delay, he was referred to our center for liver transplantation because of poor metabolic control. Following cadaveric split liver transplantation, there was complete normalization of his plasma ammonia and plasma amino acid levels under a normal protein-containing diet. This excellent metabolic control was associated with a markedly improved general condition, mood and behavior, and small developmental achievements. Twelve years after liver transplantation, the patient has a stable cognitive impairment without progression of spastic diplegia. CONCLUSION This first case of liver transplantation in HHH syndrome demonstrates that this procedure is a therapeutic option for HHH patients with difficult metabolic control.
Collapse
Affiliation(s)
- Pauline De Bruyne
- Department of Internal Medicine and Genetics, Ghent University, Ghent, Belgium
| | - Patrick Verloo
- Department of Pediatric Neurology, Princess Elisabeth Children's Hospital, Ghent University Hospital, Ghent, Belgium
| | - Johan L K Van Hove
- Department of Pediatrics, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
| | - Bernard de Hemptinne
- Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital, Ghent, Belgium
| | - Saskia Vande Velde
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Princess Elisabeth Children's Hospital, Ghent University Hospital, Ghent, Belgium
| | - Myriam Van Winckel
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Princess Elisabeth Children's Hospital, Ghent University Hospital, Ghent, Belgium
| | - Stephanie Van Biervliet
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Princess Elisabeth Children's Hospital, Ghent University Hospital, Ghent, Belgium
| | - Ruth De Bruyne
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Princess Elisabeth Children's Hospital, Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
4
|
Maharaj R, Kota V, Singh B, Kapoor D, Nageswara Rao PB, Moode J, Dekate J, Nathani P. Living Donor Liver Transplantation in a Paediatric Patient With Citrullinaemia Type 2. J Clin Exp Hepatol 2020; 10:525-528. [PMID: 33029059 PMCID: PMC7527851 DOI: 10.1016/j.jceh.2019.12.006] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 12/29/2019] [Indexed: 12/12/2022] Open
Abstract
Citrullinaemia is a urea cycle defect that results from a deficiency of the enzyme arginosuccinate synthetase. Type 1 disease is diagnosed in childhood, whereas type 2 disease is adult onset. But, we report the outcome in a boy (13 years) with citrullinaemia type 2 who received a live donor liver transplant (LDLT) at our centre. One advantage of LDLT over deceased donor liver transplantation is the opportunity to schedule surgery, which beneficially affects neurological consequences. In conclusion, transplantation should be considered to be the definitive treatment for citrullinaemia type 2 at this stage, although some issues remain unresolved.
Collapse
Affiliation(s)
- Rajiv Maharaj
- Department of Surgical Gastroenterology& Liver Transplant, Global Hospital, Hyderabad, Telanagana, India,Address for Correspondence: Rajiv Maharaj, FACS , FMAS, DNB , FMIAS, FAIS, Department of Surgical gastroenterology and Liver transplantation, Gleneagles Global hospital 6-1-1040/1- lakdikapul, Hyderabad Telangana, India.
| | - Venugopal Kota
- Department of Surgical Gastroenterology& Liver Transplant, Global Hospital, Hyderabad, Telanagana, India
| | - Balbir Singh
- Department of Surgical Gastroenterology& Liver Transplant, Global Hospital, Hyderabad, Telanagana, India
| | - Dharmesh Kapoor
- Head of the Department of Hepatology, Global Hospital, Hyderabad, Telangana, India
| | | | - Jayanth Moode
- Department of Liver Transplant Surgery, Global Hospital, Hyderabad, Telangana, India
| | - Jyoti Dekate
- Departmant of Pathology, Global Hospital, Hyderabad, Telangana, India
| | - Priya Nathani
- Departmant of Radiology, Global Hospital, Hyderabad, Telangana, India
| |
Collapse
|
5
|
Vara R, Dhawan A, Deheragoda M, Grünewald S, Pierre G, Heaton ND, Vilca-Melendez H, Hadžić N. Liver transplantation for neonatal-onset citrullinemia. Pediatr Transplant 2018; 22:e13191. [PMID: 29726081 DOI: 10.1111/petr.13191] [Citation(s) in RCA: 8] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/12/2018] [Indexed: 12/27/2022]
Abstract
Citrullinemia or ASS deficiency in its classical form presents in the neonatal period with poor feeding, hyperammonemia, encephalopathy, seizures, and if untreated can be fatal. Despite advances in medical therapy, neurocognitive outcomes remain suboptimal. LT has emerged as a potential management option. A retrospective single-center review identified 7 children with a median age of 1.1 years (range, 0.6-5.8) at referral. Five children presented clinically, and 2 were treated prospectively from birth due to positive family history. All patients received standard medical and dietary therapy prior to LT. The indications for LT were frequent metabolic decompensations in 4, elective in 2, and ALF in 1. The median age at LT was 2.4 years (range, 1.3-6.5). Five patients received 6 left lateral segment grafts, one a live unrelated donor left lateral segment as an APOLT graft, and one a cadaveric whole liver graft as APOLT. One child required retransplantation due to hepatic artery thrombosis. Graft and patient survival were 86% and 100%, respectively. Median follow-up is 3.1 years (range, 0.1-4.1), and the median age at follow-up is 5.5 years (range, 4.0-9.8). There have been no metabolic decompensations in 6 children, while 1 patient (with APOLT) developed asymptomatic hyperammonemia with no clinical or histological signs of liver injury, requiring additional medical therapy. Our medium-term experience following LT in citrullinemia is favorable, demonstrating a positive transformation of the clinical phenotype.
Collapse
Affiliation(s)
- Roshni Vara
- Department of Inherited Metabolic Disease, Evelina London Children's Hospital, London, UK.,Paediatric Liver, GI and Nutrition Centre, King's College Hospital, London, UK
| | - Anil Dhawan
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital, London, UK
| | - Maesha Deheragoda
- Liver Histopathology, Institute of Liver Studies, King's College Hospital, London, UK
| | - Stephanie Grünewald
- Department of Paediatric Inherited Metabolic Disease, Institute of Child Health, Great Ormond Street Hospital for Children, UCL, London, UK
| | - Germaine Pierre
- Department of Paediatric Inherited Metabolic Disease, Bristol Children's Hospital, Bristol, UK
| | - Nigel D Heaton
- Liver Transplantation, Institute of Liver Studies, King's College Hospital, London, UK
| | - Hector Vilca-Melendez
- Liver Transplantation, Institute of Liver Studies, King's College Hospital, London, UK
| | - Nedim Hadžić
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital, London, UK
| |
Collapse
|
6
|
Prasun P, Altinok D, Misra VK. Ornithine transcarbamylase deficiency presenting with acute reversible cortical blindness. J Child Neurol 2015; 30:782-5. [PMID: 24850570 DOI: 10.1177/0883073814535490] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [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: 08/02/2013] [Accepted: 04/14/2014] [Indexed: 11/17/2022]
Abstract
Acute focal neurologic deficits are a rare but known presentation of ornithine transcarbamylase deficiency, particularly in females. We describe here a 6-year-old girl with newly diagnosed ornithine transcarbamylase deficiency who presents with an episode of acute cortical blindness lasting for 72 hours in the absence of hyperammonemia. Her symptoms were associated with a subcortical low-intensity lesion with overlying cortical hyperintensity on fluid-attenuated inversion recovery magnetic resonance imaging (MRI) of the occipital lobes. Acute reversible vision loss with these MRI findings is an unusual finding in patients with ornithine transcarbamylase deficiency. Our findings suggest a role for oxidative stress and aberrant glutamine metabolism in the acute clinical features of ornithine transcarbamylase deficiency even in the absence of hyperammonemia.
Collapse
Affiliation(s)
- Pankaj Prasun
- Division of Genetics & Metabolic Disorders, Children's Hospital of Michigan, Detroit, MI, USA
| | - Deniz Altinok
- Pediatric Imaging, Children's Hospital of Michigan, Detroit, MI, USA
| | - Vinod K Misra
- Division of Genetics & Metabolic Disorders, Children's Hospital of Michigan, Detroit, MI, USA
| |
Collapse
|
7
|
Abstract
Urea cycle disorders (UCD) are common during neonatal period, and it is rarely reported in adults. We are reporting a patient presenting with post-partum neuropsychiatric symptoms rapidly progressing to coma. Markedly raised serum ammonia level on presentation with an initial normal magnetic resonance imaging (MRI) of brain and normal liver function tests led to the suspicion of UCD, which was confirmed on the basis of urine orotic acid and elevated serum amino acid levels. We had to resort to hemodialysis to correct the hyperammonemic coma, which was unresponsive to conventional anti-ammonia measures. She exhibited remarkable improvement with a progressive decline in serum ammonia with repeated hemodialysis and made a full recovery. Timely diagnosis and early institution of hemodialysis in the setting of a poor neurological status maybe considered a suitable treatment option.
Collapse
Affiliation(s)
- Sananta Kumar Dash
- Department of Critical Care Medicine, Indraprastha Apollo Hospital, New Delhi, India
| | | | | | | | | | | |
Collapse
|