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Tsykunova G, Kristensen E, Stray-Pedersen A, Bruserud Ø, Sørensen IW, Bruserud Ø, Tvedt THA. Adult presentation of ornithine transcarbamylase deficiency: a possible cause of hyperammonemia after high-dose chemotherapy and stem cell transplantation. Hematology 2023; 28:2265187. [PMID: 38078487 DOI: 10.1080/16078454.2023.2265187] [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: 06/03/2023] [Accepted: 09/26/2023] [Indexed: 12/18/2023] Open
Abstract
Hyperammonemia is a rare and often fatal complication following the conditioning therapy in autologous and allogeneic stem cell transplant recipients. It is characterized by anorexia, vomiting, lethargy and coma without any other apparent cause. The diagnosis is often delayed because symptoms can be subtle and ammonia is usually not included among the routine analyzes. Previous reports have not identified the molecular mechanisms behind hyperammonemia in stem cell transplant recipients. Urea cycle disorders (UCDs) are inborn errors of metabolism leading to hyperammonemia that usually presents in early childhood, whereas first presentation in adults is less common. Here we describe an adult woman with hyperammonemia following autologous stem cell transplantation for multiple myeloma. No apparent cause of hyperammonemia was identified, including portosystemic shunting, liver dysfunction or recent hyperammonemia-inducing chemotherapy. Hyperammonemia, normal blood glucose as well as anion gap and a previous history of two male newborns that died early after birth, prompted biochemical and genetic investigations for a UCD. A heterozygous variant in the X-linked gene encoding ornithine transcarbamylase (OTC) was identified and was regarded as a cause of UCD. The patient improved after treatment with nitrogen scavengers and high caloric intake according to a UCD protocol. This case report suggests that UCD should be considered as a possible cause of hyperammonemia following stem cell transplantation.
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Affiliation(s)
- Galina Tsykunova
- Department of Medicine Haukeland University Hospital, Bergen, Norway
| | - Erle Kristensen
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Asbjørg Stray-Pedersen
- The National Unit for Newborn Screening, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Øyvind Bruserud
- Department of Anesthesiology and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Ida Wiig Sørensen
- Department of Medical Genetics, Haukeland University Hospital, Bergen, Norway
| | - Øystein Bruserud
- Department of Medicine Haukeland University Hospital, Bergen, Norway
- Section for Hematology, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Tor Henrik Anderson Tvedt
- Department of Medicine Haukeland University Hospital, Bergen, Norway
- Department of Haematology, Oslo University Hospital, Oslo, Norway
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Cunningham SC, van Dijk EB, Zhu E, Sugden M, Mandwie M, Siew S, Devanapalli B, Tolun AA, Klein A, Wilson L, Aryamanesh N, Gissen P, Baruteau J, Bhattacharya K, Alexander IE. Recapitulation of Skewed X-Inactivation in Female Ornithine Transcarbamylase-Deficient Primary Human Hepatocytes in the FRG Mouse: A Novel System for Developing Epigenetic Therapies. Hum Gene Ther 2023; 34:917-926. [PMID: 37350098 DOI: 10.1089/hum.2023.011] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023] Open
Abstract
Realization of the immense therapeutic potential of epigenetic editing requires development of clinically predictive model systems that faithfully recapitulate relevant aspects of the target disease pathophysiology. In female patients with ornithine transcarbamylase (OTC) deficiency, an X-linked condition, skewed inactivation of the X chromosome carrying the wild-type OTC allele is associated with increased disease severity. The majority of affected female patients can be managed medically, but a proportion require liver transplantation. With rapid development of epigenetic editing technology, reactivation of silenced wild-type OTC alleles is becoming an increasingly plausible therapeutic approach. Toward this end, privileged access to explanted diseased livers from two affected female infants provided the opportunity to explore whether engraftment and expansion of dissociated patient-derived hepatocytes in the FRG mouse might produce a relevant model for evaluation of epigenetic interventions. Hepatocytes from both infants were successfully used to generate chimeric mouse-human livers, in which clusters of primary human hepatocytes were either OTC positive or negative by immunohistochemistry (IHC), consistent with clonal expansion from individual hepatocytes in which the mutant or wild-type OTC allele was inactivated, respectively. Enumeration of the proportion of OTC-positive or -negative human hepatocyte clusters was consistent with dramatic skewing in one infant and minimal to modest skewing in the other. Importantly, IHC and fluorescence-activated cell sorting analysis of intact and dissociated liver samples from both infants showed qualitatively similar patterns, confirming that the chimeric mouse-human liver model recapitulated the native state in each infant. Also of importance was the induction of a treatable metabolic phenotype, orotic aciduria, in mice, which correlated with the presence of clonally expanded OTC-negative primary human hepatocytes. We are currently using this unique model to explore CRISPR-dCas9-based epigenetic targeting strategies in combination with efficient adeno-associated virus (AAV) gene delivery to reactivate the silenced functional OTC gene on the inactive X chromosome.
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Affiliation(s)
- Sharon C Cunningham
- Gene Therapy Research Unit, Faculty of Medicine and Health, Children's Medical Research Institute, The University of Sydney and Sydney Children's Hospitals Network, Westmead, Australia
| | - Eva B van Dijk
- Gene Therapy Research Unit, Faculty of Medicine and Health, Children's Medical Research Institute, The University of Sydney and Sydney Children's Hospitals Network, Westmead, Australia
| | - Erhua Zhu
- Gene Therapy Research Unit, Faculty of Medicine and Health, Children's Medical Research Institute, The University of Sydney and Sydney Children's Hospitals Network, Westmead, Australia
| | - Maya Sugden
- Gene Therapy Research Unit, Faculty of Medicine and Health, Children's Medical Research Institute, The University of Sydney and Sydney Children's Hospitals Network, Westmead, Australia
| | - Mawj Mandwie
- Gene Therapy Research Unit, Faculty of Medicine and Health, Children's Medical Research Institute, The University of Sydney and Sydney Children's Hospitals Network, Westmead, Australia
| | - Susan Siew
- Department of Gastroenterology, James Fairfax Institute of Paediatric Nutrition, Sydney Children's Hospitals Network, Westmead, Australia
- Discipline of Child and Adolescent Health, Faculty of Medicine and Health, The University of Sydney, Westmead, Australia
| | - Beena Devanapalli
- NSW Biochemical Genetics Service, The Children's Hospital at Westmead, Westmead, Australia
| | - Adviye Ayper Tolun
- Discipline of Child and Adolescent Health, Faculty of Medicine and Health, The University of Sydney, Westmead, Australia
- NSW Biochemical Genetics Service, The Children's Hospital at Westmead, Westmead, Australia
| | - Anne Klein
- Australian e-Health Research Centre, Commonwealth Scientific and Industrial Research Organisation (CSIRO), Sydney, Australia
| | - Laurence Wilson
- Australian e-Health Research Centre, Commonwealth Scientific and Industrial Research Organisation (CSIRO), Sydney, Australia
- Department of Biomedical Sciences, Macquarie University, Macquarie Park, Australia
| | - Nader Aryamanesh
- Embryology Research Unit, Bioinformatics Group, Children's Medical Research Institute, University of Sydney, Westmead, Australia
| | - Paul Gissen
- National Institute for Health Research Great Ormond Street Hospital Biomedical Research Centre, University College London, London, United Kingdom
| | - Julien Baruteau
- National Institute for Health Research Great Ormond Street Hospital Biomedical Research Centre, University College London, London, United Kingdom
| | - Kaustuv Bhattacharya
- Discipline of Child and Adolescent Health, Faculty of Medicine and Health, The University of Sydney, Westmead, Australia
- Genetic Metabolic Disorders Service, The Children's Hospital at Westmead, Sydney, Australia
| | - Ian E Alexander
- Gene Therapy Research Unit, Faculty of Medicine and Health, Children's Medical Research Institute, The University of Sydney and Sydney Children's Hospitals Network, Westmead, Australia
- Discipline of Child and Adolescent Health, Faculty of Medicine and Health, The University of Sydney, Westmead, Australia
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Lo RS, Cromie GA, Tang M, Teng K, Owens K, Sirr A, Kutz JN, Morizono H, Caldovic L, Ah Mew N, Gropman A, Dudley AM. The functional impact of 1,570 individual amino acid substitutions in human OTC. Am J Hum Genet 2023; 110:863-879. [PMID: 37146589 PMCID: PMC10183466 DOI: 10.1016/j.ajhg.2023.03.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/30/2023] [Indexed: 05/07/2023] Open
Abstract
Deleterious mutations in the X-linked gene encoding ornithine transcarbamylase (OTC) cause the most common urea cycle disorder, OTC deficiency. This rare but highly actionable disease can present with severe neonatal onset in males or with later onset in either sex. Individuals with neonatal onset appear normal at birth but rapidly develop hyperammonemia, which can progress to cerebral edema, coma, and death, outcomes ameliorated by rapid diagnosis and treatment. Here, we develop a high-throughput functional assay for human OTC and individually measure the impact of 1,570 variants, 84% of all SNV-accessible missense mutations. Comparison to existing clinical significance calls, demonstrated that our assay distinguishes known benign from pathogenic variants and variants with neonatal onset from late-onset disease presentation. This functional stratification allowed us to identify score ranges corresponding to clinically relevant levels of impairment of OTC activity. Examining the results of our assay in the context of protein structure further allowed us to identify a 13 amino acid domain, the SMG loop, whose function appears to be required in human cells but not in yeast. Finally, inclusion of our data as PS3 evidence under the current ACMG guidelines, in a pilot reclassification of 34 variants with complete loss of activity, would change the classification of 22 from variants of unknown significance to clinically actionable likely pathogenic variants. These results illustrate how large-scale functional assays are especially powerful when applied to rare genetic diseases.
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Affiliation(s)
- Russell S Lo
- Pacific Northwest Research Institute, Seattle, WA, USA
| | | | - Michelle Tang
- Pacific Northwest Research Institute, Seattle, WA, USA
| | - Kevin Teng
- Pacific Northwest Research Institute, Seattle, WA, USA
| | - Katherine Owens
- Pacific Northwest Research Institute, Seattle, WA, USA; Department of Applied Mathematics, University of Washington, Seattle, WA, USA
| | - Amy Sirr
- Pacific Northwest Research Institute, Seattle, WA, USA
| | - J Nathan Kutz
- Department of Applied Mathematics, University of Washington, Seattle, WA, USA
| | - Hiroki Morizono
- Center for Genetic Medicine Research, Children's National Research Institute, Children's National Hospital, Washington, DC, USA; Department of Genomics and Precision Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Ljubica Caldovic
- Center for Genetic Medicine Research, Children's National Research Institute, Children's National Hospital, Washington, DC, USA; Department of Genomics and Precision Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Nicholas Ah Mew
- Center for Genetic Medicine Research, Children's National Research Institute, Children's National Hospital, Washington, DC, USA; Department of Genomics and Precision Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Andrea Gropman
- Center for Genetic Medicine Research, Children's National Research Institute, Children's National Hospital, Washington, DC, USA; Department of Genomics and Precision Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA; Department of Neurology, Division of Neurogenetics and Neurodevelopmental Disabilities, Children's National Hospital, Washington, DC, USA; Center for Neuroscience Research, Children's National Research Institute, Children's National Hospital, Washington, DC, USA
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高 瑞, 巴 音, 张 蓉, 曹 云, 杨 琳, 吴 冰, 周 文, 周 建. [Neonate-onset ornithine transcarbamylase deficiency]. Zhongguo Dang Dai Er Ke Za Zhi 2023; 25:431-435. [PMID: 37073851 PMCID: PMC10120332 DOI: 10.7499/j.issn.1008-8830.2302023] [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] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 03/07/2023] [Indexed: 04/20/2023]
Abstract
The male neonate in this case study was admitted to the hospital at 15 hours of age due to respiratory distress for 15 hours and poor response for 3 hours after resuscitation from asphyxia. The neonate was highly unresponsive, with central respiratory failure and seizures. Serum ammonia was elevated (>1 000 μmol/L). Blood tandem mass spectrometry revealed a significant decrease in citrulline. Rapid familial whole genome sequencing revealed OTC gene mutations inherited from the mother. Continuous hemodialysis filtration and other treatments were given. Neurological assessment was performed by cranial magnetic resonance imaging and electroencephalogram. The neonate was diagnosed with ornithine transcarbamylase deficiency combined with brain injury. He died at 6 days of age after withdrawing care. This article focuses on the differential diagnosis of neonatal hyperammonemia and introduces the multidisciplinary management of inborn error of metabolism.
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Affiliation(s)
| | | | | | | | - 琳 杨
- 国家儿童医学中心/复旦大学附属儿科医院内分泌遗传代谢科上海201102
| | - 冰冰 吴
- 国家儿童医学中心/复旦大学附属儿科医院儿科研究所上海201102
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Santamaria R, Ballester M, Garcia-Llorens G, Martinez F, Blazquez M, Ribes-Koninckx C, Castell JV, Wuestefeld T, Bort R. Derivation of healthy hepatocyte-like cells from a female patient with ornithine transcarbamylase deficiency through X-inactivation selection. Sci Rep 2022; 12:2308. [PMID: 35145162 PMCID: PMC8831560 DOI: 10.1038/s41598-022-06184-w] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 01/18/2022] [Indexed: 11/09/2022] Open
Abstract
Autologous cell replacement therapy for inherited metabolic disorders requires the correction of the underlying genetic mutation in patient's cells. An unexplored alternative for females affected from X-linked diseases is the clonal selection of cells randomly silencing the X-chromosome containing the mutant allele, without in vivo or ex vivo genome editing. In this report, we have isolated dermal fibroblasts from a female patient affected of ornithine transcarbamylase deficiency and obtained clones based on inactivation status of either maternally or paternally inherited X chromosome, followed by differentiation to hepatocytes. Hepatocyte-like cells derived from these clones display indistinct features characteristic of hepatocytes, but express either the mutant or wild type OTC allele depending on X-inactivation pattern. When clonally derived hepatocyte-like cells were transplanted into FRG® KO mice, they were able to colonize the liver and recapitulate OTC-dependent phenotype conditioned by X-chromosome inactivation pattern. This approach opens new strategies for cell therapy of X-linked metabolic diseases and experimental in vitro models for drug development for such diseases.
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Affiliation(s)
- Ramon Santamaria
- Experimental Hepatology Unit, Instituto de Investigación Sanitaria La Fe, CIBERehd, Hospital Universitari i Politècnic La Fe, Avda. Fernando Abril Martorell 106, 46026, Valencia, Spain
| | - Maria Ballester
- Experimental Hepatology Unit, Instituto de Investigación Sanitaria La Fe, CIBERehd, Hospital Universitari i Politècnic La Fe, Avda. Fernando Abril Martorell 106, 46026, Valencia, Spain
| | - Guillem Garcia-Llorens
- Experimental Hepatology Unit, Instituto de Investigación Sanitaria La Fe, CIBERehd, Hospital Universitari i Politècnic La Fe, Avda. Fernando Abril Martorell 106, 46026, Valencia, Spain
- Biochemistry and Molecular Biology Department, Universidad de Valencia, Valencia, Spain
| | - Francisco Martinez
- Genetics Unit, Instituto de Investigación Sanitaria La Fe, Hospital Universitari i Politècnic La Fe, 46026, Valencia, Spain
| | - Marina Blazquez
- Experimental Hepatology Unit, Instituto de Investigación Sanitaria La Fe, CIBERehd, Hospital Universitari i Politècnic La Fe, Avda. Fernando Abril Martorell 106, 46026, Valencia, Spain
| | - Carmen Ribes-Koninckx
- Coeliac Disease and Inmunopathology Research Unit, Instituto de Investigación Sanitaria La Fe, Pediatric Gastroenterology, Hospital Universitari i Politècnic La Fe, 46026, Valencia, Spain
| | - Jose V Castell
- Experimental Hepatology Unit, Instituto de Investigación Sanitaria La Fe, CIBERehd, Hospital Universitari i Politècnic La Fe, Avda. Fernando Abril Martorell 106, 46026, Valencia, Spain
- Biochemistry and Molecular Biology Department, Universidad de Valencia, Valencia, Spain
| | - Torsten Wuestefeld
- Laboratory for In Vivo Genetics & Gene Therapy, Genome Institute of Singapore, A*STAR & National Cancer Centre Singapore, School of Biological Science, SingHealth & Adj. Ass.-Prof. Nanyang Technological University, 60 Biopolis Street, #02-01 Genome, Singapore, 138672, Singapore
| | - Roque Bort
- Experimental Hepatology Unit, Instituto de Investigación Sanitaria La Fe, CIBERehd, Hospital Universitari i Politècnic La Fe, Avda. Fernando Abril Martorell 106, 46026, Valencia, Spain.
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Sugahara G, Yamasaki C, Yanagi A, Furukawa S, Ogawa Y, Fukuda A, Enosawa S, Umezawa A, Ishida Y, Tateno C. Humanized liver mouse model with transplanted human hepatocytes from patients with ornithine transcarbamylase deficiency. J Inherit Metab Dis 2021; 44:618-628. [PMID: 33336822 PMCID: PMC8247293 DOI: 10.1002/jimd.12347] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 12/10/2020] [Accepted: 12/16/2020] [Indexed: 12/20/2022]
Abstract
Ornithine transcarbamylase deficiency (OTCD) is a metabolic and genetic disease caused by dysfunction of the hepatocytic urea cycle. To develop new drugs or therapies for OTCD, it is ideal to use models that are more closely related to human metabolism and pathology. Primary human hepatocytes (HHs) isolated from two patients (a 6-month-old boy and a 5-year-old girl) and a healthy donor were transplanted into host mice (hemi-, hetero-OTCD mice, and control mice, respectively). HHs were isolated from these mice and used for serial transplantation into the next host mouse or for in vitro experiments. Histological, biochemical, and enzyme activity analyses were performed. Cultured HHs were treated with ammonium chloride or therapeutic drugs. Replacement rates exceeded 80% after serial transplantation in both OTCD mice. These highly humanized OTCD mice showed characteristics similar to OTCD patients that included increased blood ammonia levels and urine orotic acid levels enhanced by allopurinol. Hemi-OTCD mice showed defects in OTC expression and significantly low enzymatic activities, while hetero-OTCD mice showed residual OTC expression and activities. A reduction in ammonium metabolism was observed in cultured HHs from OTCD mice, and treatment with the therapeutic drug reduced the ammonia levels in the culture medium. In conclusion, we established in vivo OTC mouse models with hemi- and hetero-patient HHs. HHs isolated from the mice were useful as an in vitro model of OTCD. These OTC models could be a source of valuable patient-derived hepatocytes that would enable large scale and reproducible experiments using the same donor.
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Affiliation(s)
- Go Sugahara
- Research and Development DepartmentPhoenixBio Co., LtdHigashi‐HiroshimaJapan
| | - Chihiro Yamasaki
- Research and Development DepartmentPhoenixBio Co., LtdHigashi‐HiroshimaJapan
| | - Ami Yanagi
- Research and Development DepartmentPhoenixBio Co., LtdHigashi‐HiroshimaJapan
| | - Suzue Furukawa
- Research and Development DepartmentPhoenixBio Co., LtdHigashi‐HiroshimaJapan
| | - Yuko Ogawa
- Research and Development DepartmentPhoenixBio Co., LtdHigashi‐HiroshimaJapan
| | - Akinari Fukuda
- National Center for Child Health and DevelopmentTokyoJapan
| | - Shin Enosawa
- Division for Advanced Medical SciencesNational Center for Child Health and DevelopmentTokyoJapan
| | - Akihiro Umezawa
- Regenerative MedicineNational Center for Child Health and DevelopmentTokyoJapan
| | - Yuji Ishida
- Research and Development DepartmentPhoenixBio Co., LtdHigashi‐HiroshimaJapan
- Research Center for Hepatology and GastroenterologyHiroshima UniversityHiroshimaJapan
| | - Chise Tateno
- Research and Development DepartmentPhoenixBio Co., LtdHigashi‐HiroshimaJapan
- Research Center for Hepatology and GastroenterologyHiroshima UniversityHiroshimaJapan
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Cavino K, Sung B, Su Q, Na E, Kim J, Cheng X, Gromada J, Okamoto H. Glucagon Receptor Inhibition Reduces Hyperammonemia and Lethality in Male Mice with Urea Cycle Disorder. Endocrinology 2021; 162:5988952. [PMID: 33206168 DOI: 10.1210/endocr/bqaa211] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 08/07/2020] [Indexed: 12/14/2022]
Abstract
The liver plays a critical role in maintaining ammonia homeostasis. Urea cycle defects, liver injury, or failure and glutamine synthetase (GS) deficiency result in hyperammonemia, serious clinical conditions, and lethality. In this study we used a mouse model with a defect in the urea cycle enzyme ornithine transcarbamylase (Otcspf-ash) to test the hypothesis that glucagon receptor inhibition using a monoclonal blocking antibody will reduce the hyperammonemia and associated lethality induced by a high-protein diet, which exacerbates disease. We found reduced expression of glutaminase, which degrades glutamine and increased expression of GS in livers of Otcspf-ash mice treated with the glucagon receptor blocking antibody. The gene expression changes favor ammonia consumption and were accompanied by increased circulating glutamine levels and diminished hyperammonemia. Otcspf-ash mice treated with the glucagon receptor-blocking antibody gained lean and body mass and had increased survival. These data suggest that glucagon receptor inhibition using a monoclonal antibody could reduce the risk for hyperammonemia and other clinical manifestations of patients suffering from defects in the urea cycle, liver injury, or failure and GS deficiency.
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Affiliation(s)
- Katie Cavino
- Regeneron Pharmaceuticals, Tarrytown, New York USA
| | - Biin Sung
- Regeneron Pharmaceuticals, Tarrytown, New York USA
| | - Qi Su
- Regeneron Pharmaceuticals, Tarrytown, New York USA
| | - Erqian Na
- Regeneron Pharmaceuticals, Tarrytown, New York USA
| | - Jinrang Kim
- Regeneron Pharmaceuticals, Tarrytown, New York USA
| | - Xiping Cheng
- Regeneron Pharmaceuticals, Tarrytown, New York USA
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Division of Genetics and Metabolism, Child Diseases and Health Care Branch, Chinese Association for Maternal and Child Health. [Consensus on diagnosis and treatment of ornithine trans-carbamylase deficiency]. Zhejiang Da Xue Xue Bao Yi Xue Ban 2020; 49:539-547. [PMID: 33210478 PMCID: PMC8800749 DOI: 10.3785/j.issn.1008-9292.2020.04.11] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 01/15/2020] [Indexed: 12/11/2022]
Abstract
Ornithine transcarbamylase deficiency(OTCD)is a most common ornithine cycle (urea cycle) disorder. It is a X-link inherited disorder caused by OTC gene mutation that in turn leads to reduction or loss of OTC enzyme activity. Its onset time is related to the lack of enzyme activity. Patients with neonatal onset usually have complete absence of OTC enzyme activity, which is mainly associated with male semi-zygotic mutations; and the disease progresses rapidly with high mortality rates. Patients with late onset vary in onset age and clinical manifestations, and the course of disease can be progressive or intermittent. The acute attack mainly manifests neuropsychiatric symptoms accompanied by digestive symptoms like liver function damage or even acute liver failure. Elevated blood ammonia is the main biochemical indicator of OTCD patients. Increased glutamine, decreased citrulline in blood, and increased orotic acid in urine are typical clinical manifestations for OTCD patients. Genetic testing of OTC gene is important for OTCD diagnosis. The goal of treatment is to minimize the neurological damage caused by hyperammonemia while ensuring the nutritional needs for patient development. For patients with poor response to medication and diet, liver transplantation is recommended under the condition of stable metabolic state and absence of severe neurological damage. During long-term treatment, physical growth indicators, nutrition status, liver function, blood ammonia and amino acids should be regularly monitored. This consensus aims to standardize the diagnosis and treatment of OTCD, improve the prognosis, reduce the mortality and disability of patients.
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Wang L, Yang Y, Breton C, Bell P, Li M, Zhang J, Che Y, Saveliev A, He Z, White J, Latshaw C, Xu C, McMenamin D, Yu H, Morizono H, Batshaw ML, Wilson JM. A mutation-independent CRISPR-Cas9-mediated gene targeting approach to treat a murine model of ornithine transcarbamylase deficiency. Sci Adv 2020; 6:eaax5701. [PMID: 32095520 PMCID: PMC7015695 DOI: 10.1126/sciadv.aax5701] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 09/30/2019] [Indexed: 02/05/2023]
Abstract
Ornithine transcarbamylase (OTC) deficiency is an X-linked urea cycle disorder associated with high mortality. Although a promising treatment for late-onset OTC deficiency, adeno-associated virus (AAV) neonatal gene therapy would only provide short-term therapeutic effects as the non-integrated genome gets lost during hepatocyte proliferation. CRISPR-Cas9-mediated homology-directed repair can correct a G-to-A mutation in 10% of OTC alleles in the livers of newborn OTC spfash mice. However, an editing vector able to correct one mutation would not be applicable for patients carrying different OTC mutations, plus expression would not be fast enough to treat a hyperammonemia crisis. Here, we describe a dual-AAV vector system that accomplishes rapid short-term expression from a non-integrated minigene and long-term expression from the site-specific integration of this minigene without any selective growth advantage for OTC-positive cells in newborns. This CRISPR-Cas9 gene-targeting approach may be applicable to all patients with OTC deficiency, irrespective of mutation and/or clinical state.
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Affiliation(s)
- Lili Wang
- Gene Therapy Program, Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Yang Yang
- Gene Therapy Program, Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, and Collaborative Innovation Center for Biotherapy, Chengdu, Sichuan, China
| | - Camilo Breton
- Gene Therapy Program, Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Peter Bell
- Gene Therapy Program, Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Mingyao Li
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Jia Zhang
- Gene Therapy Program, Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Yan Che
- Gene Therapy Program, Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Alexei Saveliev
- Gene Therapy Program, Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Zhenning He
- Gene Therapy Program, Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - John White
- Gene Therapy Program, Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Caitlin Latshaw
- Gene Therapy Program, Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Chenyu Xu
- Center for Genetic Medicine Research, Children’s Research Institute, Children’s National Hospital, Washington, DC 20010, USA
| | - Deirdre McMenamin
- Gene Therapy Program, Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Hongwei Yu
- Gene Therapy Program, Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Hiroki Morizono
- Center for Genetic Medicine Research, Children’s Research Institute, Children’s National Hospital, Washington, DC 20010, USA
| | - Mark L. Batshaw
- Center for Genetic Medicine Research, Children’s Research Institute, Children’s National Hospital, Washington, DC 20010, USA
| | - James M. Wilson
- Gene Therapy Program, Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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10
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Stepien KM, Geberhiwot T, Hendriksz CJ, Treacy EP. Challenges in diagnosing and managing adult patients with urea cycle disorders. J Inherit Metab Dis 2019; 42:1136-1146. [PMID: 30932189 DOI: 10.1002/jimd.12096] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [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: 10/23/2018] [Accepted: 03/28/2019] [Indexed: 12/15/2022]
Abstract
Urea cycle disorders (UCD) are a group of rare inherited metabolic conditions of amino acid catabolism caused by an enzyme deficiency within the hepatic ammonia detoxification pathway. The presentation of these disorders ranges from life-threatening intoxication in the neonate to asymptomatic status in adults. Late-onset UCDs can present for the first time in adulthood and may mimic other causes of acute confusion or psychiatric diseases, and are often associated with neurological symptoms. Late-onset UCDs may become apparent during periods of metabolic stress such as rapid weight loss, gastric bypass surgery, chronic starvation or the postpartum period. Early diagnosis is critical for effective treatment and to prevent long-term complications of hyperammonemia. The challenges of management of adults include for example: (a) poor compliance to dietary and medical treatment which can result in recurrent hospital admissions; (b) severe neurological dysfunction; (c) the management of pregnancy and the postpartum period; and (d) access to multidisciplinary care peri-operatively. In this review, we highlight a number of challenges in the diagnosis and management of adult patient with late-onset UCDs and suggest a systematic management approach.
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Affiliation(s)
- Karolina M Stepien
- Mark Holland Metabolic Unit, Adult Inherited Metabolic Diseases Department, Salford Royal NHS Foundation Trust, Salford, UK
| | - Tarekegn Geberhiwot
- Centre for Endocrinology, Diabetes and Metabolism, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Christian J Hendriksz
- Department of Paediatrics, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
| | - Eileen P Treacy
- National Centre for Inherited Metabolic Diseases, The Mater Misericordiae University Hospital, Dublin, Ireland
- Department of Paediatrics, Trinity College, Dublin, Ireland
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11
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Prieve MG, Harvie P, Monahan SD, Roy D, Li AG, Blevins TL, Paschal AE, Waldheim M, Bell EC, Galperin A, Ella-Menye JR, Houston ME. Targeted mRNA Therapy for Ornithine Transcarbamylase Deficiency. Mol Ther 2018; 26:801-813. [PMID: 29433939 PMCID: PMC5910669 DOI: 10.1016/j.ymthe.2017.12.024] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [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: 07/20/2017] [Revised: 12/21/2017] [Accepted: 12/28/2017] [Indexed: 11/18/2022] Open
Abstract
We describe a novel, two-nanoparticle mRNA delivery system and show that it is highly effective as a means of intracellular enzyme replacement therapy (i-ERT) using a murine model of ornithine transcarbamylase deficiency (OTCD). Our Hybrid mRNA Technology delivery system (HMT) comprises an inert lipid nanoparticle that protects the mRNA from nucleases in the blood as it distributes to the liver and a polymer micelle that targets hepatocytes and triggers endosomal release of mRNA. This results in high-level synthesis of the desired protein specifically in the liver. HMT delivery of human OTC mRNA normalizes plasma ammonia and urinary orotic acid levels, and leads to a prolonged survival benefit in the murine OTCD model. HMT represents a unique, non-viral mRNA delivery method that allows multi-dose, systemic administration for treatment of single-gene inherited metabolic diseases.
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Affiliation(s)
- Mary G Prieve
- PhaseRx, Inc., 410 W. Harrison Street, Suite 300, Seattle, WA 98119, USA.
| | - Pierrot Harvie
- PhaseRx, Inc., 410 W. Harrison Street, Suite 300, Seattle, WA 98119, USA
| | - Sean D Monahan
- PhaseRx, Inc., 410 W. Harrison Street, Suite 300, Seattle, WA 98119, USA
| | - Debashish Roy
- PhaseRx, Inc., 410 W. Harrison Street, Suite 300, Seattle, WA 98119, USA
| | - Allen G Li
- PhaseRx, Inc., 410 W. Harrison Street, Suite 300, Seattle, WA 98119, USA
| | - Teri L Blevins
- PhaseRx, Inc., 410 W. Harrison Street, Suite 300, Seattle, WA 98119, USA
| | - Amber E Paschal
- PhaseRx, Inc., 410 W. Harrison Street, Suite 300, Seattle, WA 98119, USA
| | - Matt Waldheim
- PhaseRx, Inc., 410 W. Harrison Street, Suite 300, Seattle, WA 98119, USA
| | - Eric C Bell
- PhaseRx, Inc., 410 W. Harrison Street, Suite 300, Seattle, WA 98119, USA
| | - Anna Galperin
- PhaseRx, Inc., 410 W. Harrison Street, Suite 300, Seattle, WA 98119, USA
| | | | - Michael E Houston
- PhaseRx, Inc., 410 W. Harrison Street, Suite 300, Seattle, WA 98119, USA
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12
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Wang L, Bell P, Morizono H, He Z, Pumbo E, Yu H, White J, Batshaw ML, Wilson JM. AAV gene therapy corrects OTC deficiency and prevents liver fibrosis in aged OTC-knock out heterozygous mice. Mol Genet Metab 2017; 120:299-305. [PMID: 28283349 PMCID: PMC5423267 DOI: 10.1016/j.ymgme.2017.02.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [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: 01/12/2017] [Revised: 02/28/2017] [Accepted: 02/28/2017] [Indexed: 12/23/2022]
Abstract
Ornithine transcarbamylase (OTC) deficiency is an X-linked disorder of the urea cycle. Hemizygous males and heterozygous females may experience life-threatening elevations of ammonia in blood and brain, leading to irreversible cognitive impairment, coma, and death. Recent evidence of acute liver failure and fibrosis/cirrhosis is also emerging in OTC-deficient patients. Here, we investigated the long-term consequences of abnormal ureagenesis in female mice heterozygous (Het) for a null mutation in the OTC gene. Two-month-old Het OTC knockout (KO) mice received a single dose of self-complementary adeno-associated virus (AAV) encoding a codon-optimized human OTC gene at 1×1010, 3×1010, or 1×1011 vector genome copies per mouse. We compared liver pathology from 18-month-old treated Het OTC-KO mice, age-matched untreated Het OTC-KO mice, and WT littermates, and assessed urinary orotic acid levels and vector genome copies in liver at 4, 10, and 16months following vector administration. Het OTC-KO female mice showed evidence of liver inflammation and the eventual development of significant fibrosis. Treatment with AAV gene therapy not only corrected the underlying metabolic abnormalities, but also prevented the development of liver fibrosis. Our study demonstrates that early treatment of OTC deficiency with gene therapy may prevent clinically relevant consequences of chronic liver damage from developing.
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Affiliation(s)
- Lili Wang
- Gene Therapy Program, Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, 125 S. 31st Street, Philadelphia, PA 19104, USA
| | - Peter Bell
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 125 S. 31st Street, Philadelphia, PA 19104, USA
| | - Hiroki Morizono
- Center for Genetic Medicine Research, Children's Research Institute, Children's National Health System, 111 Michigan Ave., Washington, DC 20010, USA
| | - Zhenning He
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 125 S. 31st Street, Philadelphia, PA 19104, USA
| | - Elena Pumbo
- Center for Genetic Medicine Research, Children's Research Institute, Children's National Health System, 111 Michigan Ave., Washington, DC 20010, USA
| | - Hongwei Yu
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 125 S. 31st Street, Philadelphia, PA 19104, USA
| | - John White
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 125 S. 31st Street, Philadelphia, PA 19104, USA
| | - Mark L Batshaw
- Center for Genetic Medicine Research, Children's Research Institute, Children's National Health System, 111 Michigan Ave., Washington, DC 20010, USA
| | - James M Wilson
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 125 S. 31st Street, Philadelphia, PA 19104, USA.
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13
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Oishi Y, Kakimoto T, Yuan W, Kuno S, Yamashita H, Chiba T. Fetal Gene Therapy for Ornithine Transcarbamylase Deficiency by Intrahepatic Plasmid DNA-Micro-Bubble Injection Combined with Hepatic Ultrasound Insonation. Ultrasound Med Biol 2016; 42:1357-1361. [PMID: 26995155 DOI: 10.1016/j.ultrasmedbio.2015.10.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 10/04/2015] [Accepted: 10/12/2015] [Indexed: 06/05/2023]
Abstract
We evaluated the therapeutic efficacy of hepatic transfection of plasmid DNA using micro-bubbles and ultrasound insonation for fetal correction of ornithine transcarbamylase (OTC) deficiency in mice. Twenty-three sparse-fur heterozygous pregnant mice (day 16 of gestation) were divided into three groups: injection of plasmid-DNA micro-bubble mixture into fetal liver with ultrasound insonation (Tr, n = 11); control group 1 (C1), injection of plasmid-DNA micro-bubble mixture into fetal liver with no insonation (n = 5); and control group 2 (C2), injection of saline-micro-bubble mixture into fetal liver with ultrasound insonation (n = 7). Levels of blood ammonia and urinary orotic acid were significantly lower in the Tr group than in the C1 and C2 groups (p < 0.05, p < 0.01, respectively), whereas OTC activity was not different between groups. Therefore, ultrasound insonation with micro-bubbles enhanced plasmid DNA transfection into fetal mouse liver, leading to one of the therapeutic methods in ammonia metabolism. This might provide more time for OTC-deficient infants until liver transplantation.
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Affiliation(s)
- Yoshie Oishi
- National Center for Child Health and Development, Tokyo, Japan
| | | | - Wenji Yuan
- National Center for Child Health and Development, Tokyo, Japan
| | - Shuichi Kuno
- National Center for Child Health and Development, Tokyo, Japan
| | | | - Toshio Chiba
- National Center for Child Health and Development, Tokyo, Japan.
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14
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Oscarson M, Vassiliou D, Nordenström A, Nergårdh R, Wedell A, von Döbeln U. [Hereditary metabolic diseases with onset in adulthood. Early and correct treatment of acute symptoms can be life-saving]. Lakartidningen 2016; 113:DSHI. [PMID: 26835685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Inherited metabolic diseases usually present in the neonatal period or before school age. A growing portion of the disorders can be treated successfully, and an increasing number of patients are now treated in adult medicine. Several of the disorders also exist as attenuated variants without distinct symptoms in childhood. They can present as an acute onset event during metabolic stress in adulthood. We describe three patients with acute clinical decompensation in adulthood with severe sequelae and propose investigations to help diagnose such patients. One patient was unconscious from ammonia intoxication and developed severe neurological sequelae because of a defect in the urea cycle. A second patient had seizures caused by a defect in the conversion of homocysteine to methionine, resulting in lack of S-adenosylmethionine. A third patient had a stroke and grossly elevated homocysteine caused by undiagnosed homocystinuria. Recently there have been dramatic improvements in diagnostic methods, and new therapies are continuously being developed. Knowledge of these disorders is therefore of increasing importance also in adult medicine.
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Affiliation(s)
- Mikael Oscarson
- Karolinska universitetssjukhuset - Kliniken för endokrinologi, metabolism och diabetes Stockholm, Sweden Karolinska universitetssjukhuset - Kliniken för endokrinologi, metabolism och diabetes Stockholm, Sweden
| | - Daphne Vassiliou
- Karolinska universitetssjukhuset - Kliniken för endokrinologi, metabolism och diabetes Stockholm, Sweden Karolinska universitetssjukhuset - Kliniken för endokrinologi, metabolism och diabetes Stockholm, Sweden
| | - Anna Nordenström
- Karolinska universitetssjukhuset - Astrid Lindgrens barnsjukhus Stockholm, Sweden Karolinska universitetssjukhuset - Astrid Lindgrens barnsjukhus Stockholm, Sweden
| | - Ricard Nergårdh
- Karolinska universitetssjukhuset - Astrid Lindgrens barnsjukhus Stockholm, Sweden Karolinska universitetssjukhuset - Astrid Lindgrens barnsjukhus Stockholm, Sweden
| | - Anna Wedell
- Karolinska Institutet - Institutionen för molekylär medicin och kirurgi Stockholm, Sweden Karolinska Institutet - Institutionen för molekylär medicin och kirurgi Stockholm, Sweden
| | - Ulrika von Döbeln
- Karolinska universitetssjukhuset - Centrum för medfödda metabola sjukdomar Stockholm, Sweden arolinska universitetssjukhuset - Centrum för medfödda metabola sjukdomar Stockholm, Sweden
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15
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Rüegger CM, Lindner M, Ballhausen D, Baumgartner MR, Beblo S, Das A, Gautschi M, Glahn EM, Grünert SC, Hennermann J, Hochuli M, Huemer M, Karall D, Kölker S, Lachmann RH, Lotz-Havla A, Möslinger D, Nuoffer JM, Plecko B, Rutsch F, Santer R, Spiekerkoetter U, Staufner C, Stricker T, Wijburg FA, Williams M, Burgard P, Häberle J. Cross-sectional observational study of 208 patients with non-classical urea cycle disorders. J Inherit Metab Dis 2014; 37:21-30. [PMID: 23780642 PMCID: PMC3889631 DOI: 10.1007/s10545-013-9624-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 05/13/2013] [Accepted: 05/23/2013] [Indexed: 12/30/2022]
Abstract
Urea cycle disorders (UCDs) are inherited disorders of ammonia detoxification often regarded as mainly of relevance to pediatricians. Based on an increasing number of case studies it has become obvious that a significant number of UCD patients are affected by their disease in a non-classical way: presenting outside the newborn period, following a mild course, presenting with unusual clinical features, or asymptomatic patients with only biochemical signs of a UCD. These patients are surviving into adolescence and adulthood, rendering this group of diseases clinically relevant to adult physicians as well as pediatricians. In preparation for an international workshop we collected data on all patients with non-classical UCDs treated by the participants in 20 European metabolic centres. Information was collected on a cohort of 208 patients 50% of which were ≥ 16 years old. The largest subgroup (121 patients) had X-linked ornithine transcarbamylase deficiency (OTCD) of whom 83 were female and 29% of these were asymptomatic. In index patients, there was a mean delay from first symptoms to diagnosis of 1.6 years. Cognitive impairment was present in 36% of all patients including female OTCD patients (in 31%) and those 41 patients identified presymptomatically following positive newborn screening (in 12%). In conclusion, UCD patients with non-classical clinical presentations require the interest and care of adult physicians and have a high risk of neurological complications. To improve the outcome of UCDs, a greater awareness by health professionals of the importance of hyperammonemia and UCDs, and ultimately avoidance of the still long delay to correctly diagnose the patients, is crucial.
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Affiliation(s)
- Corinne M. Rüegger
- Division of Metabolism, University Children’s Hospital, Steinwiesstr. 75, 8032 Zurich, Switzerland
- Children’s Research Center, Zurich, Switzerland
| | - Martin Lindner
- Department of General Pediatrics, Division of Inherited Metabolic Diseases, University Hospital Heidelberg, Heidelberg, Germany
| | - Diana Ballhausen
- Inborn Errors of Metabolism, Molecular Pediatrics, Centre Hospitalier Universitaire Vaudois and University of Lausanne, 1011 Lausanne, Switzerland
| | - Matthias R. Baumgartner
- Division of Metabolism, University Children’s Hospital, Steinwiesstr. 75, 8032 Zurich, Switzerland
- Children’s Research Center, Zurich, Switzerland
| | - Skadi Beblo
- University Hospital for Children and Adolescents, University of Leipzig, Leipzig, Germany
| | - Anibh Das
- Department of Paediatrics, Hannover Medical School, Carl Neuberg Str. 1, D-30625 Hannover, Germany
| | - Matthias Gautschi
- University Children’s Hospital, Paediatric Endocrinology, Diabetes and Metabolism, University of Bern, Bern, Switzerland
| | - Esther M. Glahn
- Department of General Pediatrics, Division of Inherited Metabolic Diseases, University Hospital Heidelberg, Heidelberg, Germany
| | - Sarah C. Grünert
- Department of Pediatrics and Adolescent Medicine, University Children’s Hospital Freiburg, Freiburg, Germany
| | - Julia Hennermann
- Department of Pediatric Endocrinology, Gastroenterology and Metabolic Diseases, Charité Universitätsmedizin, Berlin, Germany
| | - Michel Hochuli
- Department of Endocrinology, Diabetes and Clinical Nutrition, University Hospital Zurich, CH-8091 Zurich, Switzerland
| | - Martina Huemer
- Department of Pediatrics, Landeskrankenhaus Bregenz, Carl Pedenz Str. 2, 6900 Bregenz, Austria
| | - Daniela Karall
- Clinic of Pediatrics I, Division Metabolic Inherited Disorders, Medical University Innsbruck, Innsbruck, Austria
| | - Stefan Kölker
- Department of General Pediatrics, Division of Inherited Metabolic Diseases, University Hospital Heidelberg, Heidelberg, Germany
| | - Robin H. Lachmann
- National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG UK
| | - Amelie Lotz-Havla
- Department of Inborn Errors of Metabolism, Dr. von Hauner Children’s Hospital, Ludwig-Maximilians-University, Munich, 80337 Germany
| | - Dorothea Möslinger
- Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Waehringerguertel 18-20, 1090 Vienna, Austria
| | - Jean-Marc Nuoffer
- University Children’s Hospital, Paediatric Endocrinology, Diabetes and Metabolism, University of Bern, Bern, Switzerland
- University Institute of Clinical Chemistry, University Bern, Bern, Switzerland
| | - Barbara Plecko
- Children’s Research Center, Zurich, Switzerland
- Department of Pediatrics, University Hospital Graz, Auenbruggerplatz 30, A-8036 Graz, Austria
- Division of Neuropediatrics, University Children’s Hospital, Zurich, Switzerland
| | - Frank Rutsch
- Department of General Pediatrics, Münster University Children’s Hospital, Münster, Germany
| | - René Santer
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Ute Spiekerkoetter
- Department of Pediatrics and Adolescent Medicine, University Children’s Hospital Freiburg, Freiburg, Germany
- Department of General Pediatrics and Neonatology, University Children’s Hospital Duesseldorf, Duesseldorf, Germany
| | - Christian Staufner
- Department of General Pediatrics, Division of Inherited Metabolic Diseases, University Hospital Heidelberg, Heidelberg, Germany
| | - Tamar Stricker
- Division of Metabolism, University Children’s Hospital, Steinwiesstr. 75, 8032 Zurich, Switzerland
- Children’s Research Center, Zurich, Switzerland
| | - Frits A. Wijburg
- Department of Pediatrics, Academic Medical Centre, Amsterdam, The Netherlands
| | - Monique Williams
- Department of Pediatrics, Erasmus Medical Center, Sophia Children’s Hospital Rotterdam, Rotterdam, The Netherlands
| | - Peter Burgard
- Department of General Pediatrics, Division of Inherited Metabolic Diseases, University Hospital Heidelberg, Heidelberg, Germany
| | - Johannes Häberle
- Division of Metabolism, University Children’s Hospital, Steinwiesstr. 75, 8032 Zurich, Switzerland
- Children’s Research Center, Zurich, Switzerland
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16
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Samuel N, Politansky AK, Hoffman R, Itzkovich S, Mandel H. Coagulopathy unmasking hepatic failure in a child with ornithine transcarbamylase deficiency. Isr Med Assoc J 2013; 15:777-779. [PMID: 24449986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Nir Samuel
- Department of Pediatrics B, Meyer Children's Hospital, Rambam Health Care Campus, Haifa, Israel.
| | - Anat K Politansky
- Thrombosis and Hemostasis Unit, Rambam Health Care Campus, Haifa, Israel
| | - Ron Hoffman
- Thrombosis and Hemostasis Unit, Rambam Health Care Campus, Haifa, Israel
| | - Shlomit Itzkovich
- Clinical Nutrition Unit, Meyer Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Hanna Mandel
- Department of Pediatrics B, Meyer Children's Hospital, Rambam Health Care Campus, Haifa, Israel
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17
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Wang L, Wang H, Morizono H, Bell P, Jones D, Lin J, McMenamin D, Yu H, Batshaw ML, Wilson JM. Sustained correction of OTC deficiency in spf( ash) mice using optimized self-complementary AAV2/8 vectors. Gene Ther 2012; 19:404-10. [PMID: 21850052 PMCID: PMC3321078 DOI: 10.1038/gt.2011.111] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [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: 02/28/2011] [Accepted: 05/18/2011] [Indexed: 12/26/2022]
Abstract
Ornithine transcarbamylase deficiency (OTCD) is the most common inborn error of urea synthesis. Complete OTCD can result in hyperammonemic coma in the neonatal period, which can rapidly become fatal. Current acute therapy involves dialysis; chronic therapy involves the stimulation of alternate nitrogen clearance pathways; and the only curative approach is liver transplantation. Adeno-associated virus (AAV) vector-based gene therapy would add to current treatment options provided the vector delivers high level and stable transgene expression in liver without dose-limiting toxicity. In this study, we employed an AAV2/8-based self-complementary (sc) vector expressing the murine OTC (mOTC) gene under a liver-specific thyroxine-binding globulin promoter and examined the therapeutic effects in a mouse model of OTCD, the spf (ash) mouse. Seven days after a single intravenous injection of vector, treated mice showed complete normalization of urinary orotic acid, a measure of OTC activity. We further improved vector efficacy by incorporating a Kozak or Kozak-like sequence into mOTC complementary DNA, which increased the OTC activity by five or twofold and achieved sustained correction of orotic aciduria for up to 7 months. Our results demonstrate that vector optimizations can significantly improve the efficacy of gene therapy.
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Affiliation(s)
- Lili Wang
- Gene Therapy Program, Department of Pathology and Laboratory Medicine, Division of Transfusion Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Huan Wang
- Gene Therapy Program, Department of Pathology and Laboratory Medicine, Division of Transfusion Medicine, University of Pennsylvania, Philadelphia, PA 19104
- Vaccine Research Institute, Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Hiroki Morizono
- Center for Genetic Medicine Research, Children’s National Medical Center, Children’s Research Institute, Washington, District of Columbia, USA
| | - Peter Bell
- Gene Therapy Program, Department of Pathology and Laboratory Medicine, Division of Transfusion Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - David Jones
- Center for Genetic Medicine Research, Children’s National Medical Center, Children’s Research Institute, Washington, District of Columbia, USA
| | - Jianping Lin
- Gene Therapy Program, Department of Pathology and Laboratory Medicine, Division of Transfusion Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Deirdre McMenamin
- Gene Therapy Program, Department of Pathology and Laboratory Medicine, Division of Transfusion Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Hongwei Yu
- Gene Therapy Program, Department of Pathology and Laboratory Medicine, Division of Transfusion Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Mark L. Batshaw
- Center for Genetic Medicine Research, Children’s National Medical Center, Children’s Research Institute, Washington, District of Columbia, USA
| | - James M. Wilson
- Gene Therapy Program, Department of Pathology and Laboratory Medicine, Division of Transfusion Medicine, University of Pennsylvania, Philadelphia, PA 19104
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18
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Wilson JM, Shchelochkov OA, Gallagher RC, Batshaw ML. Hepatocellular carcinoma in a research subject with ornithine transcarbamylase deficiency. Mol Genet Metab 2012; 105:263-5. [PMID: 22129577 PMCID: PMC3273986 DOI: 10.1016/j.ymgme.2011.10.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [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: 09/27/2011] [Revised: 10/25/2011] [Accepted: 10/25/2011] [Indexed: 12/22/2022]
Abstract
A 66 year old woman who is a manifesting heterozygote for ornithine transcarbamylase deficiency (OTCD) presented with hepatocellular carcinoma (HCC). Fourteen years prior to this presentation she participated in a phase I gene therapy study which used an adenoviral vector, thought to be non-oncogenic, to deliver a normal OTC gene to hepatocytes [1]. A recent review of data collected through a national longitudinal study of individuals with urea cycle defects [2,3] suggests that early urea cycle disorders (UCDs) are associated with hepatocellular damage and liver dysfunction in many cases. This may predispose an affected individual to a substantially increased risk of developing HCC, as has been observed in certain other inborn errors of metabolism. We speculate that the underlying urea cycle defect may be the cause of HCC in this individual.
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Affiliation(s)
- James M Wilson
- Gene Therapy Program, Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
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19
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Wang L, Morizono H, Lin J, Bell P, Jones D, McMenamin D, Yu H, Batshaw ML, Wilson JM. Preclinical evaluation of a clinical candidate AAV8 vector for ornithine transcarbamylase (OTC) deficiency reveals functional enzyme from each persisting vector genome. Mol Genet Metab 2012; 105:203-11. [PMID: 22133298 PMCID: PMC3270700 DOI: 10.1016/j.ymgme.2011.10.020] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [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: 08/24/2011] [Revised: 10/31/2011] [Accepted: 10/31/2011] [Indexed: 10/15/2022]
Abstract
Ornithine transcarbamylase deficiency (OTCD), the most common and severe urea cycle disorder, is an excellent model for developing liver-directed gene therapy. No curative therapy exists except for liver transplantation which is limited by available donors and carries significant risk of mortality and morbidity. Adeno-associated virus 8 (AAV8) has been shown to be the most efficient vector for liver-directed gene transfer and is currently being evaluated in a clinical trial for treating hemophilia B. In this study, we generated a clinical candidate vector for a proposed OTC gene therapy trial in humans based on a self-complementary AAV8 vector expressing codon-optimized human OTC (hOTCco) under the control of a liver-specific promoter. Codon-optimization dramatically improved the efficacy of OTC gene therapy. Supraphysiological expression levels and activity of hOTC were achieved in adult spf(ash) mice following a single intravenous injection of hOTCco vector. Vector doses as low as 1×10(10) genome copies (GC) achieved robust and sustained correction of the OTCD biomarker orotic aciduria and clinical protection against an ammonia challenge. Functional expression of hOTC in 40% of liver areas was found in mice treated with a low vector dose of 1×10(9) GC. We suggest that the clinical candidate vector we have developed has the potential to achieve therapeutic effects in OTCD patients.
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Affiliation(s)
- Lili Wang
- Gene Therapy Program, Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Hiroki Morizono
- Center for Genetic Medicine Research, Children’s National Medical Center, Children’s Research Institute, Washington, D.C., USA
| | - Jianping Lin
- Gene Therapy Program, Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter Bell
- Gene Therapy Program, Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David Jones
- Center for Genetic Medicine Research, Children’s National Medical Center, Children’s Research Institute, Washington, D.C., USA
| | - Deirdre McMenamin
- Gene Therapy Program, Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Hongwei Yu
- Gene Therapy Program, Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mark L. Batshaw
- Center for Genetic Medicine Research, Children’s National Medical Center, Children’s Research Institute, Washington, D.C., USA
| | - James M. Wilson
- Gene Therapy Program, Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Corresponding author: Department of Pathology and Laboratory Medicine University of Pennsylvania, Philadelphia, PA 19104, USA Phone: 215-898-0226; Fax: 215-494-5444
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Nagasaka H, Yorifuji T, Kobayashi K, Takikawa H, Komatsu H, Inui A, Fujisawa T, Miida T, Tsukahara H, Takatani T, Hayashi H. Favorable effect of 4-phenylacetate on liver functions attributable to enhanced bile salt export pump expression in ornithine transcarbamylase-deficient children. Mol Genet Metab 2010; 100:123-8. [PMID: 20219403 DOI: 10.1016/j.ymgme.2010.02.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [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: 02/10/2010] [Accepted: 02/10/2010] [Indexed: 10/19/2022]
Abstract
4-Phenylbutyrate (4-PB) acting against hyperammonemia has been administered to patients with urea cycle defects. Results of our recent experiments using animals and cultured cells strongly suggest that this agent enhances the function of bile salt export pump/ATP binding cassette B11 (BSEP/ABCB11) promoting bile acid excretion from hepatocytes to bile canaliculi, although it has not been confirmed in humans. Considering that 4-PB is converted easily into 4-phenylacetate (4-PA) in the liver, such an effect of 4-PB might occur through 4-PA. We performed retrospective analyzes of the effects of 4-PA on the liver functions of three ornithine transcarbamylase (OTC)-deficient female children receiving 4-PA. Two of the three received intravenous administration of 4-PA only at episodic periods of hyperammonemia; the remaining one received it orally at intercurrent periods. Soon after 4-PA administration, the serum total bile acid level was decreased to one-half or one-third of pre-treatment levels, but it returned to the basal levels within one month after 4-PA discontinuation. Other serum parameters for cholestasis such as gamma-glutamyl transferase also decreased markedly. Concomitantly, alanine aminotransferase and aspartate amino transferase levels decreased significantly. Western blot analyzes of the liver samples revealed that the 4-PA administration enhanced BSEP/ABCB11 protein expressions in the membranous fraction of liver cells, although the liver BSEP/ABCB11 messenger RNA level remained unchanged. These results suggest that 4-PA enhanced liver BSEP/ABCB11 function and thereby improved liver functions in OTC-deficient children. For treatment of liver disorders requiring enhancement of BSEP function, 4-PA might be a candidate.
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Affiliation(s)
- Hironori Nagasaka
- Division of Metabolism, Chiba Children's Hospital, Midori-ku, Chiba, Japan.
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21
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Gene therapy: concepts and methods. Few applications so far. Prescrire Int 2009; 18:276-9. [PMID: 20027718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
(1) Gene therapy consists of inserting foreign genetic material into a patient's cells to correct a health disorder; (2) Only a fraction of gene therapy trials involve hereditary single-gene disorders. Most trials focus on acquired disorders such as cancer and cardiovascular disease; (3) The therapeutic gene can be delivered directly into the target organ or the general circulation, or alternatively into cells that are first isolated from the patient and then reinjected; (4) One of the main problems with gene therapy is finding an appropriate vector (viral or non-viral) that is both effective and safe. Most currently available vectors confer only weak and transient therapeutic gene expression. In addition, many carry major risks such as immunological disorders and oncogenicity; (5) In early 2009, only one therapeutic gene product is commercially available, in China.
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Abstract
The urea cycle is the final pathway for removal of surplus nitrogen from the body, and the major route in humans for detoxification of ammonia. The full complement of enzymes is expressed only in liver. Inherited deficiencies of urea cycle enzymes lead to hyperammonaemia, which causes brain damage. Severe defects present with hyperammonaemic crises in neonates. Equally devastating episodes may occur in previously asymptomatic adults with mild defects, most often X-linked ornithine transcarbamylase (OTC) deficiency. Several mechanisms probably contribute to pathogenesis. Treatment aims to reduce plasma ammonia quickly, reduce production of waste nitrogen, dispose of waste nitrogen using alternative pathways to the urea cycle and replace arginine. These therapies have increased survival and probably improve the neurological outcome. Arginine, sodium benzoate, sodium phenylbutyrate and, less often, sodium phenylacetate are used. Long-term correction is achieved by liver transplantation. Gene therapy for OTC deficiency is effective in animals, and work is ongoing to improve persistence and safety.
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Affiliation(s)
- V Walker
- Department of Clinical Biochemistry, Southampton University Hospitals NHS Trust, Southampton General Hospital, Southampton, UK. valerie.walker @suht.swest.nhs.uk
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23
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Cunningham SC, Spinoulas A, Carpenter KH, Wilcken B, Kuchel PW, Alexander IE. AAV2/8-mediated correction of OTC deficiency is robust in adult but not neonatal Spf(ash) mice. Mol Ther 2009; 17:1340-6. [PMID: 19384294 PMCID: PMC2835243 DOI: 10.1038/mt.2009.88] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2008] [Accepted: 03/30/2009] [Indexed: 11/08/2022] Open
Abstract
Ornithine transcarbamylase (OTC) deficiency, the most common urea cycle disorder, is associated with severe hyperammonemia accompanied by a high risk of neurological damage and death in patients presenting with the neonatal-onset form. Contemporary therapies, including liver transplantation, remain inadequate with considerable morbidity, justifying vigorous investigation of alternate therapies. Clinical evidence suggests that as little as 3% normal enzyme activity is sufficient to ameliorate the severe neonatal phenotype, making OTC deficiency an ideal model for the development of liver-targeted gene therapy. In this study, we investigated metabolic correction in neonatal and adult male OTC-deficient Spf(ash) mice following adeno-associated virus (AAV)2/8-mediated delivery of the murine OTC complementary DNA under the transcriptional control of a liver-specific promoter. Substantially supraphysiological levels of OTC enzymatic activity were readily achieved in both adult and neonatal mice following a single intraperitoneal (i.p.) injection, with metabolic correction in adults being robust and life-long. In the neonates, however, full metabolic correction was transient, although modest levels of OTC expression persisted into adulthood. Although not directly testable in Spf(ash) mice, these levels were theoretically sufficient to prevent hyperammonemia in a null phenotype. This loss of expression in the neonatal liver is the consequence of hepatocellular proliferation and presents an added challenge to human therapy.
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Affiliation(s)
- Sharon C Cunningham
- Gene Therapy Research Unit, Children's Medical Research Institute and The Children's Hospital at Westmead, Wentworthville, New South Wales, Australia
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Bürle M, Mende H, Plum U, Bluthardt M, Walka M, Geldner G. [Ornithine transcarbamylase deficiency in adolescence and adulthood: first manifestation with life-threatening decompensation]. Anaesthesist 2009; 58:594-601. [PMID: 19468698 DOI: 10.1007/s00101-009-1540-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Ornithine transcarbamylase (OTC) deficiency is the most frequent innate disorder of the urea cycle and is X-chromosome linked. The disease normally manifests itself shortly after birth and is fatal when untreated. Due to the different expression and X-chromosomal inheritance the manifestation of symptoms can appear later particularly in girls and young women. The first symptoms are non-specific signs of elevated cerebral pressure as a result of a hyperammonemia, which range from nausea and headache up to cerebral herniation with fatal outcome. Measurement of plasma ammonia levels is a simple yet important screening test for patients with unexpected stupor or delirium. CASE REPORTS The two case reports show the clinical range from acute decompensation with acute cerebral herniation followed by fatal outcome to recovery under emergency therapy without substantial neurological deficits. THERAPY Emergency treatment consists of symptomatic securing of vital parameters and an immediate reduction in the ammonia level using high calorie, protein-free nutrition to avoid catabolism together with administration of arginine, benzoate or phenyl butyrate. In cases of coma with severe cerebral edema and the threat of a herniation reaction or excessive ammonia levels, emergency hemodialysis must be immediately carried out. CONCLUSIONS In the clinical routine it is extremely important to consider a metabolic defect at an early phase and among others to determine the ammonia level so that the appropriate treatment can be instigated in time.
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Affiliation(s)
- M Bürle
- Klinik für Anästhesiologie, Intensivmedizin, Schmerztherapie und Notfallmedizin, Klinikum Ludwigsburg, Posilipostr. 4, 71640, Ludwigsburg, Deutschland.
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Abstract
Almost a decade has passed since the untimely death of Jesse Gelsinger. The reflections of Dr. Wilson and efforts made on a national scale to address various ethical issues in biomedical research provide an opportunity to consider what progress has been made in efforts to build and restore the public's trust in biomedical research. The restoration of public trust is especially critical in the aftermath of tragic events like Mr. Gelsinger's death and the authors note the need for greater emphasis on building public trust than has occurred to date in the broader biomedical research community.
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Affiliation(s)
- Mark Yarborough
- Center for Bioethics and Humanities, University of Colorado Denver, Mail Stop B 137, 13120 E. 19th Avenue, Aurora, CO 80045, USA.
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Abstract
It has been 9 years since Mr. Jesse Gelsinger died from complications of vector administration in a liver gene therapy trial of research subjects with a deficiency of ornithine transcarbamylase (OTCD). This study was performed at the Institute for Human Gene Therapy of the University of Pennsylvania (Penn) which I directed. His tragic death provoked a series of events that had implications beyond those directly involved in the clinical trial. The events surrounding the death of this research subject have been the topic of much coverage and commentary in the popular press. The goal of this article is to share with you my reflections on the OTCD gene therapy trial and lessons that I have learned which may be of value to others engaged in various aspects of translational medicine.
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Affiliation(s)
- James M Wilson
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Suite 2000 TRL, 125 S. 31st Street, Philadelphia, PA 19104-3403, USA.
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Tuchman M, Lee B, Lichter-Konecki U, Summar ML, Yudkoff M, Cederbaum SD, Kerr DS, Diaz GA, Seashore MR, Lee HS, McCarter RJ, Krischer JP, Batshaw ML. Cross-sectional multicenter study of patients with urea cycle disorders in the United States. Mol Genet Metab 2008; 94:397-402. [PMID: 18562231 PMCID: PMC2640937 DOI: 10.1016/j.ymgme.2008.05.004] [Citation(s) in RCA: 150] [Impact Index Per Article: 9.4] [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: 04/08/2008] [Revised: 05/07/2008] [Accepted: 05/07/2008] [Indexed: 11/23/2022]
Abstract
Inherited urea cycle disorders comprise eight disorders (UCD), each caused by a deficiency of one of the proteins that is essential for ureagenesis. We report on a cross-sectional investigation to determine clinical and laboratory characteristics of patients with UCD in the United States. The data used for the analysis was collected at the time of enrollment of individuals with inherited UCD into a longitudinal observation study. The study has been conducted by the Urea Cycle Disorders Consortium within the Rare Diseases Clinical Research Network (RDCRN) funded by the National Institutes of Health. One-hundred eighty-three patients were enrolled into the study. Ornithine transcarbamylase (OTC) deficiency was the most frequent disorder (55%), followed by argininosuccinic aciduria (16%) and citrullinemia (14%). Seventy-nine percent of the participants were white (16% Latinos), and 6% were African American. Intellectual and developmental disabilities were reported in 39% with learning disabilities (35%) and half had abnormal neurological examination. Sixty-three percent were on a protein restricted diet, 37% were on Na-phenylbutyrate and 5% were on Na-benzoate. Forty-five percent of OTC deficient patients were on L-citrulline, while most patients with citrullinemia (58%) and argininosuccinic aciduria (79%) were on L-arginine. Plasma levels of branched-chain amino acids were reduced in patients treated with ammonia scavenger drugs. Plasma glutamine levels were higher in proximal UCD and in neonatal type disease. The RDCRN allows comprehensive analyses of rare inherited UCD, their frequencies and current medical practices.
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Affiliation(s)
- Mendel Tuchman
- Children's National Medical Center, The George Washington University, School of Medicine, 111 Michigan Avenue, N.W., Washington, DC 20010, USA
| | - Brendan Lee
- Baylor College of Medicine, Houston, TX, USA
| | - Uta Lichter-Konecki
- Children's National Medical Center, The George Washington University, School of Medicine, 111 Michigan Avenue, N.W., Washington, DC 20010, USA
| | | | - Marc Yudkoff
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | | | | | | | - Robert J McCarter
- Children's National Medical Center, The George Washington University, School of Medicine, 111 Michigan Avenue, N.W., Washington, DC 20010, USA
| | | | - Mark L Batshaw
- Children's National Medical Center, The George Washington University, School of Medicine, 111 Michigan Avenue, N.W., Washington, DC 20010, USA
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Marcus N, Scheuerman O, Hoffer V, Zilbershot-Fink E, Reiter J, Garty BZ. Stupor in an adolescent following Yom Kippur fast, due to late-onset ornithine transcarbamylase deficiency. Isr Med Assoc J 2008; 10:395-396. [PMID: 18605371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Nufar Marcus
- Department of Pediatrics B, Schneider Children's Medical Center of Israel, Petah Tikva, Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.
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Mak CM, Siu TS, Lam CW, Chan GCF, Poon GWK, Wong KY, Low LCK, Tang NL, Li SK, Lau KY, Kwong NS, Tam S. Complete recovery from acute encephalopathy of late-onset ornithine transcarbamylase deficiency in a 3-year-old boy. J Inherit Metab Dis 2007; 30:981. [PMID: 17922216 DOI: 10.1007/s10545-007-0692-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [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: 05/28/2007] [Revised: 08/14/2007] [Accepted: 08/15/2007] [Indexed: 10/22/2022]
Abstract
Ornithine transcarbamylase deficiency is the commonest urea cycle disorder which is transmitted in X-linked inheritance. It is mainly characterized in males by acute encephalopathy and hyperammonaemia with fatal outcomes in both classical neonatal and late-onset types. We report a 3-year-old healthy Hong Kong Chinese boy who presented with acute encephalopathy and coma after three days of gastroenteritis. He had no focal neurological deficit and brain CT imaging was normal. His plasma ammonia (54 micromol/L) and glutamine (747 micromol/L) concentrations were normal. The only biochemical abnormalities detected were marked orotic aciduria (700 micromol/mmol creatinine) and elevated urinary uracil. He regained consciousness spontaneously after three days under intensive care with parenteral fluid therapy. He recovered completely without any neurological deficits. Five months after discharge, urinary uracil concentration remained elevated despite normalized orotic acid concentration. Finally, ornithine transcarbamylase deficiency was diagnosed by DNA analysis. A missense mutation of arginine-to-glutamine substitution on amino acid 277 (p.R277Q) was revealed to be a late-onset mutant. Our case strengthens the argument that in any child with coma or acute encephalopathy of undetermined cause, genetic analysis of the OTC gene and the measurement of urinary uracil concentration remain the most reliable indicators of late-onset OTCD during acute and even quiescent phases. Existing neonatal screening programmes for inheritable metabolic disorders fail to detect late-onset variants. Therefore, a high clinical suspicion is a key to correct and timely diagnosis, especially in those patients with atypical presentations.
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Affiliation(s)
- C M Mak
- Division of Clinical Biochemistry, Queen Mary Hospital, Hong Kong, SAR, China.
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Lai YC, Huang HP, Tsai IJ, Tsau YK. High-Volume Continuous Venovenous Hemofiltration as an Effective Therapy for Acute Management of Inborn Errors of Metabolism in Young Children. Blood Purif 2007; 25:303-8. [PMID: 17643056 DOI: 10.1159/000106102] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2006] [Accepted: 04/26/2007] [Indexed: 12/31/2022]
Abstract
BACKGROUND/AIM Renal replacement therapies (RRTs) have been used for the acute management of inborn errors of metabolism. Hemodialysis is the most effective modality. The aim of this article is to demonstrate that high-volume hemofiltration can offer an alternative way to effectively remove small molecules. METHODS Eight patients presented with acute neurological deterioration due to ammonia or organic acid accumulation. Different RRTs were applied, including continuous venovenous hemofiltration (CVVH, n = 7), continuous arteriovenous hemofiltration (CAVH, n = 2), continuous venovenous hemodialysis (CVVHD, n = 1), intermittent hemodialysis (HD, n = 1), and peritoneal dialysis (PD, n = 2). RESULTS Ammonia 50% reduction time in HD was 1.7 h while in CVVH it was 2-14.5 h. The greater the ultrafiltration flow was, the sooner patients regained consciousness. CAVH, CVVHD or PD was not sufficient enough. CONCLUSION CVVH also has a good clearance for organic acid and ammonia if applying high-volume hemofiltration (>35 ml/kg/h). It can be therefore be considered as an alternative therapy if infant HD is not available.
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Affiliation(s)
- Yi-Chun Lai
- Division of Pediatric Nephrology, Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
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31
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Bell P, Moscioni AD, McCarter RJ, Wu D, Gao G, Hoang A, Sanmiguel JC, Sun X, Wivel NA, Raper SE, Furth EE, Batshaw ML, Wilson JM. Analysis of tumors arising in male B6C3F1 mice with and without AAV vector delivery to liver. Mol Ther 2006; 14:34-44. [PMID: 16682254 DOI: 10.1016/j.ymthe.2006.03.008] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2005] [Revised: 02/22/2006] [Accepted: 03/07/2006] [Indexed: 10/24/2022] Open
Abstract
The present study reports on the frequency of liver tumors observed in a gene therapy study with AAV vectors in male mice of the B6C3F1 hybrid background, which are known to have a high frequency of spontaneous liver tumors. Male mice with mutations in their Otc gene and their wild-type siblings received AAV vectors expressing either the murine Otc or the LacZ gene. Untreated control animals were included in the study. All experimental groups, including wild-type and OTC-deficient animals not treated with vector, developed liver nodules, which in some cases were due to hepatocellular carcinoma. Vector DNA was lower in tumors than in adjacent normal liver. A statistical analysis of the data did not show an association between treatment with Otc vectors and formation of tumors in OTC-deficient mice. However, mice treated with LacZ vectors showed increased risks of tumor formation and hepatocellular carcinoma relative to untreated animals or animals that had received vectors with Otc as the transgene. It appears that AAV vectors alone do not contribute to the formation of tumors in these strains of mice although the expression of LacZ alone or in combination with vector may be problematic.
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Affiliation(s)
- Peter Bell
- Gene Therapy Program, Division of Medical Genetics, Department of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA 19104, USA
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Moscioni D, Morizono H, McCarter RJ, Stern A, Cabrera-Luque J, Hoang A, Sanmiguel J, Wu D, Bell P, Gao GP, Raper SE, Wilson JM, Batshaw ML. Long-term correction of ammonia metabolism and prolonged survival in ornithine transcarbamylase-deficient mice following liver-directed treatment with adeno-associated viral vectors. Mol Ther 2006; 14:25-33. [PMID: 16677864 DOI: 10.1016/j.ymthe.2006.03.009] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2005] [Revised: 02/12/2006] [Accepted: 03/14/2006] [Indexed: 11/25/2022] Open
Abstract
The purpose of this study was to determine the efficacy of novel recombinant adeno-associated viral (AAV) vector constructs in correcting metabolic defects in the liver in two strains of ornithine transcarbamylase (OTC)-deficient mice (spf and spf-ash). AAV vectors expressing mouse OTC were produced with capsids from AAV2 and the novel serotypes AAV7, 8, and 9. OTC-deficient mice were infused with these vectors as well as a control AAV2/8 vector expressing LacZ. In vivo activity of OTC was assessed by measuring a surrogate marker, urine orotate. The novel vectors restored orotate levels to virtually normal 15 days after infusion, and each persisted to 1 year posttreatment. Liver OTC enzyme activity in spf mice was substantially higher in animals receiving novel vectors compared to those receiving AAV2 vectors. Animals receiving novel OTC-expressing vectors lived longer than those treated with AAV2 OTC or untreated controls, and they were tolerant to a challenge with NH3 at 21 days and beyond, which caused severe morbidity in control OTC-deficient animals. Numerous mice, representative of all treatment groups followed for +250 days, were observed to have either nodules or discrete tumors in the liver, the etiology of which is the subject of a companion paper.
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Affiliation(s)
- David Moscioni
- Gene Therapy Program, Division of Medical Genetics, Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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Thakur V, Rupar CA, Ramsay DA, Singh R, Fraser DD. Fatal cerebral edema from late-onset ornithine transcarbamylase deficiency in a juvenile male patient receiving valproic acid. Pediatr Crit Care Med 2006; 7:273-6. [PMID: 16575347 DOI: 10.1097/01.pcc.0000216682.56067.23] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [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] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aims of this report are to 1) present a rare case of fatal cerebral edema associated with late-onset ornithine transcarbamylase (OTC) deficiency in a juvenile male patient receiving valproic acid and 2) review the neuropathologic changes associated with the hyperammonemia. DESIGN Case report. SETTING A community hospital and a tertiary pediatric critical care unit. INTERVENTIONS Carbohydrate administration, intravenous nitrogen excretion cocktail, and high-flux hemodialysis. MEASUREMENTS AND MAIN RESULTS Despite aggressive therapy for presumed late-onset OTC deficiency, the patient rapidly developed fatal cerebral edema with tonsillar herniation. A liver biopsy confirmed OTC deficiency with approximately 3% of residual hepatic enzyme activity. Chromosomal analysis showed a normal male karyotype. A thorough molecular analysis of the coding region in the OTC gene Xp21.1 was completed, but mutations were not identified, suggesting an upstream or downstream abnormality. Severe brain swelling was evident on neuropathology, and histopathology showed Alzheimer type II astrocytes, neuronal cytoplasmic changes, and hypertrophy and eosinophilia of the small arterial walls. CONCLUSIONS OTC deficiency is the most common urea cycle defect causing hyperammonemia. Late-onset presentations of OTC are infrequent, primarily affecting female patients. We present a rare case of a late-onset OTC deficiency in a juvenile male patient receiving valproic acid therapy who developed fatal cerebral edema. Valproic acid exacerbates acute elevations in ammonia and may contribute synergistically with ammonia to cerebral mitochondrial dysfunction.
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Affiliation(s)
- Varsha Thakur
- Department of Paediatrics, Children's Hospital of Western Ontario, London, Ontario, Canada
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Summar ML, Barr F, Dawling S, Smith W, Lee B, Singh RH, Rhead WJ, Sniderman King L, Christman BW. Unmasked adult-onset urea cycle disorders in the critical care setting. Crit Care Clin 2006; 21:S1-8. [PMID: 16227111 DOI: 10.1016/j.ccc.2005.05.002] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Most often, urea cycle disorders have been described as acute onset hyperammonemia in the newborn period; however, there is a growing awareness that urea cycle disorders can present at almost any age, frequently in the critical care setting. This article presents three cases of adult-onset hyperammonemia caused by inherited defects in nitrogen processing in the urea cycle, and reviews the diagnosis, management, and pathophysiology of adult-onset urea cycle disorders. Individuals who have milder molecular urea cycle defects can lead a relatively normal life until a severe environmental stress triggers a hyperammonemic crisis. Comorbid conditions such as physical trauma often delay the diagnosis of the urea cycle defect. Prompt recognition and treatment are essential in determining the outcome of these patients.
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Affiliation(s)
- Marshall L Summar
- Center for Human Genetic Research, Division of Medical Genetics, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232-0165, USA.
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35
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Hawrot-Kawecka AM, Kawecki GP, Duława J. [Hyperammonemia type II as an example of urea cycle disorder]. Wiad Lek 2006; 59:512-5. [PMID: 17209350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Ornithine transcarbamylase deficiency is the most common inherited urea cycle disorder. Its clinical manifestations as lethargy, vomites, coma and cerebral edema are the effect of the higher concentration of the ammonia in plasma. Hyperammonemia, caused by mutation in ornithine transcarbamylase gene, is often considered as a reason of coma by pediatricians but skipped by internist, although it is the third reason of hepatic coma in adults. This article is the recapitulation of published studies and their implication on everyday clinical practice.
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Affiliation(s)
- Anna M Hawrot-Kawecka
- Z Kliniki Chorób Wewnqtrznych i Metabolicznych Slaskiej Akademii Medycznej, Katowicach.
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Abstract
Today, patients with urea cycle disorder (UCD) may survive well beyond infancy. The goal of keeping them in consistent nitrogen balance can be undermined by changing metabolic needs throughout various stages of life, resulting in hyperammonemia in the short term, and poor growth and development in the long term. The specific UCD genotype can affect the risk of metabolic destabilization and management difficulties, as can variable protein tolerance secondary to changing growth demands, biochemical complications, and environmental influences. Preventing catabolic stress is as important as controlling dietary protein intake for avoiding metabolic decompensation. Optimal treatment, specifically pharmacologic therapy, possible branched chain amino acid (BCAA) supplementation, accurate laboratory monitoring, and psychosocial support, requires thorough understanding and careful application of each component.
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Affiliation(s)
- Brendan Lee
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA.
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37
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Smith W, Kishnani PS, Lee B, Singh RH, Rhead WJ, Sniderman King L, Smith M, Summar M. Urea Cycle Disorders: Clinical Presentation Outside the Newborn Period. Crit Care Clin 2005; 21:S9-17. [PMID: 16227115 DOI: 10.1016/j.ccc.2005.05.007] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Although most commonly associated with infancy, the majority of individuals with urea cycle disorders (UCDs) present outside the neonatal period, frequently in childhood. Signs and symptoms are often vague, but recurrent; fulminant presentations associated with acute illness are also common. A disorder of urea cycle metabolism should be considered in children who have recurrent symptoms, especially neurologic abnormalities associated with periods of decompensation. Routine laboratory tests, including measurement of plasma ammonia concentrations, can indicate a potential UCD; however, specific metabolic testing and ultimately enzymatic or molecular confirmation are necessary to establish a diagnosis. Treatment with dietary protein restriction and medications may be challenging in children.
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Affiliation(s)
- Wendy Smith
- Maine Pediatric Specialty Group, Portland, ME 04102, USA.
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38
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Ensenauer R, Tuchman M, El-Youssef M, Kotagal S, Ishitani MB, Matern D, Babovic-Vuksanovic D. Management and outcome of neonatal-onset ornithine transcarbamylase deficiency following liver transplantation at 60 days of life. Mol Genet Metab 2005; 84:363-6. [PMID: 15781198 DOI: 10.1016/j.ymgme.2004.12.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [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: 09/27/2004] [Revised: 12/23/2004] [Accepted: 12/28/2004] [Indexed: 10/25/2022]
Abstract
Neonatal hyperammonemia secondary to X-linked ornithine transcarbamylase (OTC) deficiency carries a high risk of morbidity and mortality. Results of medical therapy are less than satisfactory. Experience with liver transplantation in very young affected infants is limited. We report a male newborn with severe OTC deficiency who underwent successful orthotopic, cadaveric liver transplantation at the age of 60 days. Although technically challenging in the neonatal period, liver transplantation should be considered early as the most promising treatment approach currently available.
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Affiliation(s)
- Regina Ensenauer
- Department of Medical Genetics, Mayo Clinic College of Medicine, Rochester, MN, USA
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39
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McBride KL, Miller G, Carter S, Karpen S, Goss J, Lee B. Developmental outcomes with early orthotopic liver transplantation for infants with neonatal-onset urea cycle defects and a female patient with late-onset ornithine transcarbamylase deficiency. Pediatrics 2004; 114:e523-6. [PMID: 15466081 DOI: 10.1542/peds.2004-0198] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Urea cycle defects (UCDs) typically present with hyperammonemia, the duration and peak levels of which are directly related to the neurologic outcome. Liver transplantation can cure the underlying defect for some conditions, but the preexisting neurologic status is a major factor in the final outcome. Multicenter data indicate that most of the children who receive transplants remain significantly neurologically impaired. We wanted to determine whether aggressive metabolic management of ammonia levels after early referral/transfer to a metabolism center and early liver transplantation would result in better neurologic outcomes. We report on 5 children with UCDs, ie, 2 male patients with X-linked ornithine transcarbamylase deficiency and 2 male patients with carbamoyl phosphate synthase deficiency, all of whom had neonatal presentations and underwent orthotopic liver transplantation before 1 year of age, and 1 female patient with partial X-linked ornithine transcarbamylase deficiency that was intractable to medical therapy, who underwent transplantation at 35 months of age. Developmental testing with the Griffiths scale was performed on 3 occasions each, 12 months apart, up to 45 months after transplantation. Full-scale indices for 3 children who underwent early transplantation showed average developmental quotients of 67. All 5 children had metabolic cures. There were no deaths (30-month survival rate: 100%). One child is currently listed for repeat transplantation because of bile duct stenosis and cirrhosis. We conclude that early liver transplantation and aggressive metabolic management improve early neurologic outcomes for children with UCDs, but longer follow-up monitoring is needed.
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Affiliation(s)
- Kim L McBride
- Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA
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40
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Abstract
Several recent reviews describe the management of urea cycle disorders. There is much agreement on diet, alternative pathway therapy, maintenance of arginine and ornithine levels in acute and chronic management, sick-day regimens, and some aspects of monitoring. However, differences remain in several areas, and physicians at most treatment centers have relatively little experience, because these disorders are rare. Early suspicion of the diagnosis of a urea cycle disorder, and prompt referral to a tertiary center is vital. Drug treatment using chronic administration of sodium benzoate has been abandoned by some centers, but the acceptability of phenylbutyrate is an issue for many patients. Using citrulline chronically is not always successful in recommended doses, and may result in an arginine level too low for maximum control. Appetite and nutrition problems are common. One major concern is the early identification and management of chronic catabolism, theoretically easy, but hard in practice. Biochemical measurement problems complicate monitoring, and there are disagreements about the optimum way of identifying OTC carriers. It is not always clear whom to treat. Within a kindred with an early-onset phenotype, an asymptomatic newborn girl may need treatment for some undetermined time, but target values for monitoring are not clear. In late-onset phenotypes, management of asymptomatic males identified by family screening is also difficult. Most centers do not have sufficient cases to solve these conundrums, some of which require further multicenter study. This paper examines the recommendations of a consensus conference on management, outlines some remaining problems, and incorporates in the text the points raised in open discussion during a session of a symposium held in Sydney in 2003 entitled "New Developments in Urea Cycle Disorders."
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Affiliation(s)
- Bridget Wilcken
- The Children's Hospital at Westmead and the Discipline of Paediatrics, University of Sydney, Sydney, Australia.
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41
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Enkai S, Yamamoto M, Hayashi K, Kobayashi M, Sasajima T, Amizuka T, Abo W. Experience of continuous haemodiafiltration in a male neonate with ornithine transcarbamylase deficiency. Eur J Pediatr 2003; 162:729-30. [PMID: 12898242 DOI: 10.1007/s00431-003-1289-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2003] [Accepted: 06/30/2003] [Indexed: 12/31/2022]
Affiliation(s)
- Shigehiro Enkai
- Neonatal Intensive Care Unit, Department of Paediatrics, Aomori Central Hospital, 2-1-1 Higashi-Tsukurimichi, 030-8553 Aomori, Japan
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42
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Raper SE, Chirmule N, Lee FS, Wivel NA, Bagg A, Gao GP, Wilson JM, Batshaw ML. Fatal systemic inflammatory response syndrome in a ornithine transcarbamylase deficient patient following adenoviral gene transfer. Mol Genet Metab 2003; 80:148-58. [PMID: 14567964 DOI: 10.1016/j.ymgme.2003.08.016] [Citation(s) in RCA: 942] [Impact Index Per Article: 44.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
We report the death of an 18-year-old male with partial ornithine transcarbamylase (OTC) deficiency who participated in a pilot (safety) study of gene therapy. The vector used for this trial was based on human adenovirus type 5, deleted in E1 and E4, and contained human OTC cDNA. It was infused into the right hepatic artery at a dose of 6x10(11)particles/kg. Approximately 18 h. following gene transfer the subject was noted to have altered mental status and jaundice--clinical signs not seen in any of the first 17 subjects in this study. Subsequently, his clinical course was marked by systemic inflammatory response syndrome, biochemically detectable disseminated intravascular coagulation, and multiple organ system failure, leading to death 98 h following gene transfer. Post-mortem examination was consistent with the clinical course, and vector DNA sequences were readily detectable in most tissues. The subject had high serum levels of IL-6 and IL-10 but normal TNFalpha immediately after infusion of the vector. This experience points to the limitations of animal studies in predicting human responses, the steep toxicity curve for replication defective adenovirus vectors, substantial subject-to-subject variation in host responses to systemically administered vectors, and the need for further study of the immune response to these vectors.
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Affiliation(s)
- Steven E Raper
- Department of Surgery, University of Pennsylvania School of Medicine, BRB II/III Rm, 607 421 Curie Blvd, Philadelphia, PA 19104, USA.
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43
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Abstract
OBJECTIVE Transplantation of isolated hepatocytes in animal models has been shown to correct inborn errors of metabolism. Based on these studies and our experience with hepatocyte transplantation in a child with Crigler-Najjar syndrome, isolated hepatocyte transplantation was performed to attempt metabolic reconstitution in a male infant with severe ornithine transcarbamylase (OTC) deficiency. METHODS An infant with an antenatal diagnosis of OTC deficiency was managed intensively to prevent hyperammonemia. Isolated hepatocytes were obtained by collagenase perfusion of donated livers not used for transplantation. Hepatocytes were infused in batches over the first 4 weeks of life via an umbilical venous catheter positioned in the portal vein. Immunosuppression consisted of tacrolimus and corticosteroids. RESULTS Over 4 billion viable hepatocytes were transplanted during the first 3.5 weeks of life. A period of metabolic stability was achieved between days 20 and 31 during which normal protein intake was tolerated while phenylbutyrate was weaned. During this time, plasma ammonia and glutamine remained within normal limits. Hyperammonemia reappeared abruptly on day 31 of life. Protein tolerance diminished to baseline; metabolic stability was subsequently reattained only following successful liver transplantation at 6 months of age. CONCLUSIONS Isolated hepatocyte transplantation appeared to result in temporary relief of hyperammonemia and protein intolerance attributable to OTC deficiency. The metabolic stability achieved was lost after 11 days presumably because of rejection of the transplanted cells because of insufficient immunosuppression. Future attempts at isolated hepatocyte transplantation for inborn errors of metabolism in humans should include adequate immunosuppression and a liver biopsy as a means of proving hepatocyte engraftment and function.
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Affiliation(s)
- Simon P Horslen
- Section of Pediatric Gastroenterology, University of Nebraska Medical Center, Omaha, Nebraska 68198-3285, USA.
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44
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Gaspari R, Arcangeli A, Mensi S, Wismayer DS, Tartaglione T, Antuzzi D, Conti G, Proietti R. Late-onset presentation of ornithine transcarbamylase deficiency in a young woman with hyperammonemic coma. Ann Emerg Med 2003; 41:104-9. [PMID: 12514690 DOI: 10.1067/mem.2003.6] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Ornithine transcarbamylase deficiency (OTCD) is an X-linked inherited disease and the most common inborn error in urea synthesis in human patients. In adult heterozygous patients, OTCD can be responsible for life-threatening hyperammonemic coma. We report the case of a 32-year-old woman admitted to our hospital with seizures after a recent high protein load. Her parents related a history of recurrent episodes of vomiting, meat refusal, lethargy, and convulsions since childhood, and measurement of plasma ammonemia levels was the key to early diagnosis of OTCD. We report the pathophysiologic characteristics, clinical features, clinical course, and differential diagnosis of OTCD and discuss the therapeutic options, including continuous venovenous hemodiafiltration and pharmacologic therapy for reduction of plasma ammonemia levels. A diagnosis of OTCD should be considered in adult nonhepatic patients with hyperammonemic coma, particularly if they have a history of protein avoidance and neurologic symptoms. Early recognition and appropriate treatment are critical to avoid severe brain damage and death.
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Affiliation(s)
- Rita Gaspari
- Department of Anaesthesiology and Intensive Care, Catholic University of Rome, Rome, Italy.
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45
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Mäkynen H, Kahri J, Siitonen A, Sipilä I. [Progressing unconsciousness in a young male]. Duodecim 2002; 116:1841-4. [PMID: 12001638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Affiliation(s)
- H Mäkynen
- HUS:n kirurginen sairaala, anestesiaosasto PL 263, 00029 HUS.
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46
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Lee JY, Chang SE, Suh CW, Choi JH, Sung KJ, Moon KC, Koh JK. A case of acrodermatitis enteropathica-like dermatosis caused by ornithine transcarbamylase deficiency. J Am Acad Dermatol 2002; 46:965-7. [PMID: 12063505 DOI: 10.1067/mjd.2002.120595] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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47
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Gelsinger P. Jesse's intent. Bull Med Ethics 2002:13-20. [PMID: 12739533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
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48
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Matsuda I. [Ornithine transcarbamylase deficiency]. Nihon Rinsho 2002; 60 Suppl 4:775-8. [PMID: 12013997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
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49
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Abstract
Not surprisingly, clinical trials have been critically important to developments in the field of biotechnology. Perhaps less expectedly, the clinical trials of biotechnology products have been critically important to recent developments in the field of clinical trials design, conduct, and analysis. This manuscript explores three examples of biotechnology clinical trials--a trial in sepsis, a trial in fibrinolytics in myocardial infarction, and trials in gene therapy--and highlights their contributions to the theory and practice of clinical research.
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Affiliation(s)
- Jay P Siegel
- Office of Therapeutics Research and Review, Center for Biologics Evaluation and Research, US Food and Drug Administration, Rockville, Maryland 20852, USA
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50
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Raper SE, Yudkoff M, Chirmule N, Gao GP, Nunes F, Haskal ZJ, Furth EE, Propert KJ, Robinson MB, Magosin S, Simoes H, Speicher L, Hughes J, Tazelaar J, Wivel NA, Wilson JM, Batshaw ML. A pilot study of in vivo liver-directed gene transfer with an adenoviral vector in partial ornithine transcarbamylase deficiency. Hum Gene Ther 2002; 13:163-75. [PMID: 11779420 DOI: 10.1089/10430340152712719] [Citation(s) in RCA: 282] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Ornithine transcarbamylase deficiency (OTCD) is an inborn error of urea synthesis that has been considered as a model for liver-directed gene therapy. Current treatment has failed to avert a high mortality or morbidity from hyperammonemic coma. Restoration of enzyme activity in the liver should suffice to normalize metabolism. An E1- and E4-deleted vector based on adenovirus type 5 and containing human OTC cDNA was infused into the right hepatic artery in adults with partial OTCD. Six cohorts of three or four subjects received 1/2 log-increasing doses of vector from 2 x 10(9) to 6 x 10(11) particles/kg. This paper describes the experience in all but the last subject, who experienced lethal complications. Adverse effects included a flu-like episode and a transient rise in temperature, hepatic transaminases, thrombocytopenia, and hypophosphatemia. Humoral responses to the vector were seen in all research subjects and a proliferative cellular response to the vector developed in apparently naive subjects. In situ hybridization studies showed transgene expression in hepatocytes of 7 of 17 subjects. Three of 11 subjects with symptoms related to OTCD showed modest increases in urea cycle metabolic activity that were not statistically significant. The low levels of gene transfer detected in this trial suggest that at the doses tested, significant metabolic correction did not occur.
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Affiliation(s)
- Steven E Raper
- Institute for Human Gene Therapy and Department of Surgery, University of Pennsylvania, Philadelphia, PA 19104, USA
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