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Kuypers AM, Vliet KEV, MacDonald A, Ahring K, Abeln D, Ford S, Hildebrandt-Karlsen S, van Spronsen FJ, Heiner-Fokkema MR. Satisfaction with home blood sampling methods and expectations for future point-of-care testing in phenylketonuria: Perspectives from patients and professionals. Mol Genet Metab 2024; 142:108361. [PMID: 38442492 DOI: 10.1016/j.ymgme.2024.108361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION Phenylketonuria (PKU) requires regular phenylalanine monitoring to ensure optimal outcome. However, home sampling methods used for monitoring suffer high pre-analytical variability, inter-laboratory variability and turn-around-times, highlighting the need for alternative methods of home sampling or monitoring. METHODS A survey was distributed through email and social media to (parents of) PKU patients and professionals working in inherited metabolic diseases in Denmark, The Netherlands, and United Kingdom regarding satisfaction with current home sampling methods and expectations for future point-of-care testing (POCT). RESULTS 210 parents, 156 patients and 95 professionals completed the survey. Countries, and parents and patients were analysed together, in absence of significant group differences for most questions. Important results are: 1) Many patients take less home samples than advised. 2) The majority of (parents of) PKU patients are (somewhat) dissatisfied with their home sampling method, especially with turn-around-times (3-5 days). 3) 37% of professionals are dissatisfied with their home sampling method and 45% with the turn-around-times. 4) All responders are positive towards developments for POCT: 97% (n = 332) of (parents of) patients is willing to use a POC-device and 76% (n = 61) of professionals would recommend their patients to use a POC-device. 5) Concerns from all participants for future POC-devices are costs/reimbursements and accuracy, and to professionals specifically, accessibility to results, over-testing, patient anxiety, and patients adjusting their diet without consultation. CONCLUSION The PKU community is (somewhat) dissatisfied with current home sampling methods, highlighting the need for alternatives of Phe monitoring. POCT might be such an alternative and the community is eager for its arrival.
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Affiliation(s)
- Allysa M Kuypers
- Section of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Kimber Evers-van Vliet
- Section of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Anita MacDonald
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Steelhouse Lane, Birmingham B4 6NH, UK
| | | | | | - Suzanne Ford
- The National Society for Phenylketonuria (NSPKU), Richard House, Lancashire, UK
| | | | - Francjan J van Spronsen
- Section of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - M Rebecca Heiner-Fokkema
- Laboratory of Metabolic Diseases, Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
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Feldmann R, Och U, Beckmann LS, Weglage J, Rutsch F. Children and Adolescents with Early Treated Phenylketonuria: Cognitive Development and Fluctuations of Blood Phenylalanine Levels. Int J Environ Res Public Health 2024; 21:431. [PMID: 38673342 PMCID: PMC11050632 DOI: 10.3390/ijerph21040431] [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] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 03/23/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND We assessed the relationship between the cognitive development of children and adolescents with phenylketonuria (PKU) and fluctuations in peripheral phenylalanine (Phe) levels. METHODS We examined the neurocognitive performance of 33 children and adolescents with early treated PKU, of whom 18 were treated with sapropterin dihydrochloride, and 15 were on a classic diet. For 26 weeks, patients were assessed weekly for their blood phenylalanine (Phe) levels. Phe levels were analyzed for fluctuations indicated by the individual standard deviation. Fluctuations were compared to the standard deviation of 26 Phe level measurements before the study interval. We also assessed the concurrent IQ of the patients. This was repeated at one-, two-, and seven-year intervals. RESULTS Full-scale IQ in patients treated with a classic diet did not change within the follow-up. In patients treated with Sapropterin dihydrochloride, however, there was a considerable gain in full-scale IQ. This was particularly true if blood Phe fluctuations increased in patients of this treatment group. CONCLUSIONS Sapropterin dihydrochloride enhances Phe tolerance in patients with PKU. Increasing blood Phe fluctuations following enhanced Phe tolerance may indicate that the treatment not only allows patients to relax their Phe-restricted diet but also may support cognitive development in patients.
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Affiliation(s)
- Reinhold Feldmann
- Department of General Pediatrics, Münster University Children’s Hospital, 48149 Münster, Germany; (U.O.); (F.R.)
- Children’s Healthcare Center “Haus Walstedde”, 48317 Drensteinfurt, Germany
| | - Ulrike Och
- Department of General Pediatrics, Münster University Children’s Hospital, 48149 Münster, Germany; (U.O.); (F.R.)
| | - Lisa Sophie Beckmann
- Department of General Pediatrics, Münster University Children’s Hospital, 48149 Münster, Germany; (U.O.); (F.R.)
| | - Josef Weglage
- Children’s Healthcare Center “Haus Walstedde”, 48317 Drensteinfurt, Germany
| | - Frank Rutsch
- Department of General Pediatrics, Münster University Children’s Hospital, 48149 Münster, Germany; (U.O.); (F.R.)
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Bratkovic D, Margvelashvili L, Tchan MC, Nisbet J, Smith N. PTC923 (sepiapterin) lowers elevated blood phenylalanine in subjects with phenylketonuria: a phase 2 randomized, multi-center, three-period crossover, open-label, active controlled, all-comers study. Metabolism 2022; 128:155116. [PMID: 34973284 DOI: 10.1016/j.metabol.2021.155116] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 10/21/2021] [Accepted: 12/21/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND & AIM PTC923 (formerly CNSA-001), an oral formulation of sepiapterin, a natural precursor of intracellular tetrahydrobiopterin (BH4), has been shown in humans to induce larger increases in circulating BH4 vs. sapropterin dihydrochloride. Sapropterin reduces blood phenylalanine (Phe) by ≥20-30% in a minority of subjects with PKU. This was a Phase 2 randomized, multicenter, three-period crossover, open-label, active controlled, all-comers [regardless of phenylalanine hydroxylase (PAH) variants] comparison of PTC923 60 mg/kg, PTC923 20 mg/kg and sapropterin 20 mg/kg in 24 adults with phenylketonuria (PKU) and hyperphenylalaninemia. METHODS Eligible subjects were adult men or women (18-60 y) with PKU. Subjects enrolled received 7 days of once-daily oral treatment with PTC923 20 mg/kg/day, PTC923 60 mg/kg/day and sapropterin dihydrochloride 20 mg/kg/day each in a random order. Treatments were separated by a 7-day washout. Subjects maintained their usual pre-study diet, including consumption of amino acid mixtures. Blood Phe was measured on Day 1 (predose baseline), Day 3, Day 5, and Day 7 of each treatment period. RESULTS Least squares mean changes (SE) from baseline in blood Phe were: -206.4 (41.8) μmol/L for PTC923 60 mg/kg (p < 0.0001); -146.9 (41.8) μmol/L for PTC923 20 mg/kg (p = 0.0010); and - 91.5 (41.7) μmol/L for sapropterin (p = 0.0339). Effects of PTC923 60 mg/kg on blood Phe vs. sapropterin were significantly larger (p = 0.0098) and faster in onset with a significantly larger mean reduction in blood Phe at day 3 of treatment, p = 0.0135 (20 mg/kg) and p = 0.0007 (60 mg/kg). Only PTC923 60 mg/kg reduced blood Phe in classical PKU subjects (n = 11, p = 0.0287). The mean blood Phe reduction (PTC923 60 mg/kg) in a cofactor responder analysis (n = 8; baseline Phe ≥300 μmol/L and blood Phe reduction ≥30%) was -463.3 μmol/L (SE 51.5) from baseline. Adverse events were mostly mild to moderate, transient, and similar across treatment groups with no serious adverse events or discontinuations. CONCLUSIONS The substantially significantly better effect of PTC923 60 mg/kg on blood Phe reduction vs. sapropterin supports further clinical development of PTC923 for PKU; ANZCTR number, ACTRN12618001031257.
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Affiliation(s)
- Drago Bratkovic
- PARC Clinical Research, Royal Adelaide Hospital, South Australia, Australia
| | | | - Michel C Tchan
- Department of Genetic Medicine, Westmead Hospital, Australia and University of Sydney, Sydney, New South Wales, Australia
| | - Janelle Nisbet
- Mater Misericordiae Limited, Queensland Diabetes and Endocrine Centre, Brisbane, Queensland, Australia
| | - Neil Smith
- PTC Therapeutics Inc, South Plainfield, NJ, USA.
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Manek R, Zhang YV, Berthelette P, Hossain M, Cornell CS, Gans J, Anarat-Cappillino G, Geller S, Jackson R, Yu D, Singh K, Ryan S, Bangari DS, Xu EY, Kyostio-Moore SRM. Blood phenylalanine reduction reverses gene expression changes observed in a mouse model of phenylketonuria. Sci Rep 2021; 11:22886. [PMID: 34819582 PMCID: PMC8613214 DOI: 10.1038/s41598-021-02267-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 11/09/2021] [Indexed: 12/02/2022] Open
Abstract
Phenylketonuria (PKU) is a genetic deficiency of phenylalanine hydroxylase (PAH) in liver resulting in blood phenylalanine (Phe) elevation and neurotoxicity. A pegylated phenylalanine ammonia lyase (PEG-PAL) metabolizing Phe into cinnamic acid was recently approved as treatment for PKU patients. A potentially one-time rAAV-based delivery of PAH gene into liver to convert Phe into tyrosine (Tyr), a normal way of Phe metabolism, has now also entered the clinic. To understand differences between these two Phe lowering strategies, we evaluated PAH and PAL expression in livers of PAHenu2 mice on brain and liver functions. Both lowered brain Phe and increased neurotransmitter levels and corrected animal behavior. However, PAL delivery required dose optimization, did not elevate brain Tyr levels and resulted in an immune response. The effect of hyperphenylalanemia on liver functions in PKU mice was assessed by transcriptome and proteomic analyses. We observed an elevation in Cyp4a10/14 proteins involved in lipid metabolism and upregulation of genes involved in cholesterol biosynthesis. Majority of the gene expression changes were corrected by PAH and PAL delivery though the role of these changes in PKU pathology is currently unclear. Taken together, here we show that blood Phe lowering strategy using PAH or PAL corrects both brain pathology as well as previously unknown lipid metabolism associated pathway changes in liver.
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Affiliation(s)
- Rachna Manek
- Genomic Medicine Unit, Sanofi, Framingham, MA, USA.
| | - Yao V Zhang
- Genomic Medicine Unit, Sanofi, Framingham, MA, USA
| | | | | | | | - Joseph Gans
- Translational Sciences, Sanofi, Framingham, MA, USA
| | | | - Sarah Geller
- Pre-Development Sciences NA, Analytical R&D, Sanofi, Framingham, MA, USA
| | | | - Dan Yu
- Genomic Medicine Unit, Sanofi, Framingham, MA, USA
| | - Kuldeep Singh
- Global Discovery Pathology, Sanofi, Framingham, MA, USA
| | - Sue Ryan
- Global Discovery Pathology, Sanofi, Framingham, MA, USA
| | | | - Ethan Y Xu
- Translational Sciences, Sanofi, Framingham, MA, USA
- Excision BioTherapeutics, Cambridge, MA, USA
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Scala I, Concolino D, Nastasi A, Esposito G, Crisci D, Sestito S, Ferraro S, Albano L, Ruoppolo M, Parenti G, Strisciuglio P. Beneficial Effects of Slow-Release Large Neutral Amino Acids after a Phenylalanine Oral Load in Patients with Phenylketonuria. Nutrients 2021; 13:nu13114012. [PMID: 34836270 PMCID: PMC8618154 DOI: 10.3390/nu13114012] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 10/29/2021] [Accepted: 11/05/2021] [Indexed: 11/16/2022] Open
Abstract
The mainstay of phenylketonuria treatment is a low protein diet, supplemented with phenylalanine (Phe)-free protein substitutes and micronutrients. Adhering to this diet is challenging, and even patients with good metabolic control who follow the dietary prescriptions in everyday life ignore the recommendations occasionally. The present study explores the ability of slow-release large neutral amino acids (srLNAAs) to prevent Phe increase following a Phe dietary load. Fourteen phenylketonuric patients aged ≥13 years were enrolled in a 6-week protocol. Oral acute Phe loads of 250 and 500 mg were added to the evening meal together with srLNAAs (0.5 gr/kg). Phe and tyrosine were dosed before dinner, 2h-after dinner, and after the overnight fast. After oral Phe loads, mean plasma Phe remained stable and below 600 µmol/L. No Phe peaks were registered. Tyrosine levels significantly increased, and Phe/Tyrosine ratio decreased. No adverse events were registered. In conclusion, a single oral administration of srLNAAs at the dose of 0.5 gr/kg is effective in maintaining stable plasma Phe during acute oral loads with Phe-containing food and may be added to the dietetic scheme in situations in which patients with generally good adherence to diet foresee a higher than prescribed Phe intake due to their commitments.
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Affiliation(s)
- Iris Scala
- Department of Maternal and Child Health, Federico II University Hospital, 80131 Naples, Italy
- Correspondence: ; Tel.: +39-081-7463348; +39-081-7463769
| | - Daniela Concolino
- Pediatric Unit, Department of Health Sciences, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy; (D.C.); (S.S.); (S.F.)
| | - Anna Nastasi
- Physiology Nutrition Unit, Department of Clinical Medicine and Surgery, Federico II University, 80131 Naples, Italy;
| | - Giulia Esposito
- Department of Translational Medical Science, Section of Pediatrics, Federico II University, 80131 Naples, Italy; (G.E.); (G.P.); (P.S.)
| | - Daniela Crisci
- CEINGE Biotecnologie Avanzate Scarl, 80131 Naples, Italy; (D.C.); (L.A.); (M.R.)
| | - Simona Sestito
- Pediatric Unit, Department of Health Sciences, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy; (D.C.); (S.S.); (S.F.)
| | - Stefania Ferraro
- Pediatric Unit, Department of Health Sciences, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy; (D.C.); (S.S.); (S.F.)
| | - Lucia Albano
- CEINGE Biotecnologie Avanzate Scarl, 80131 Naples, Italy; (D.C.); (L.A.); (M.R.)
| | - Margherita Ruoppolo
- CEINGE Biotecnologie Avanzate Scarl, 80131 Naples, Italy; (D.C.); (L.A.); (M.R.)
- Department of Molecular Medicine and Medical Biotechnologies, Federico II University, 80131 Naples, Italy
| | - Giancarlo Parenti
- Department of Translational Medical Science, Section of Pediatrics, Federico II University, 80131 Naples, Italy; (G.E.); (G.P.); (P.S.)
- Telethon Institute of Genetics and Medicine, 80078 Pozzuoli, Italy
| | - Pietro Strisciuglio
- Department of Translational Medical Science, Section of Pediatrics, Federico II University, 80131 Naples, Italy; (G.E.); (G.P.); (P.S.)
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6
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Aitkenhead L, Krishna G, Ellerton C, Moinuddin M, Matcham J, Shiel L, Hossain S, Kiffin M, Foley J, Skeath R, Cleary M, Lachmann R, Murphy E. Long-term cognitive and psychosocial outcomes in adults with phenylketonuria. J Inherit Metab Dis 2021; 44:1353-1368. [PMID: 34145605 DOI: 10.1002/jimd.12413] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 08/12/2020] [Revised: 05/31/2021] [Accepted: 06/16/2021] [Indexed: 12/22/2022]
Abstract
Previous studies have suggested that cognitive and psychosocial underfunctioning in early-treated adults with phenylketonuria (PKU) may be explained by suboptimal adherence to dietary treatments, however, these studies often employ small samples, with different outcome measures, definitions and cut-offs. Samples have also tended to comprise participants with a limited range of blood phenylalanine concentrations, and often individuals who may not have been treated early enough to avoid neurological damage. In this study, we explore the impact of lifetime dietary control, as indicated by blood phenylalanine concentrations in childhood, adolescence and adulthood, on long-term cognitive and psychosocial outcomes in a large sample of adults with PKU who were diagnosed by neonatal screening and commenced on dietary treatment within the first month of life. One hundred and fifty-four participants underwent cognitive testing, assessing attention, learning, working memory, language, executive functioning and processing speed. One hundred and forty-nine completed measures of psychosocial functioning, documenting educational, occupational, quality of life, emotional and social outcomes which were compared with a group of healthy controls. Many adults with PKU demonstrated cognitive impairments, most frequently affecting processing speed (23%), executive function (20%) and learning (12%). Cognitive outcomes were related to measures of historic metabolic control, but only processing speed was significantly related to phenylalanine concentration at the time of testing after controlling for historic levels. Adults with PKU did not, however, differ from controls in educational, occupational, quality of life or emotional outcomes, or on a measure of family functioning, and showed only minor differences in relationship style. These findings have implications for patient counselling and decisions regarding the management of PKU in adulthood.
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Affiliation(s)
- Lynne Aitkenhead
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
- UCL Institute of Neurology, London, UK
| | - Gauri Krishna
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Charlotte Ellerton
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Md Moinuddin
- UCL Institute of Child Health, London, UK
- Faculty of Health, Social Care & Medicine, Edge Hill University, Ormskirk, UK
| | - Jessica Matcham
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Lisha Shiel
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Shasoty Hossain
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Marianne Kiffin
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Jennifer Foley
- UCL Institute of Neurology, London, UK
- Department of Neuropsychology, National Hospital of Neurology & Neurosurgery, London, UK
| | - Rachel Skeath
- Department of Metabolic Medicine, Great Ormond Street Hospital, London, UK
| | - Maureen Cleary
- Department of Metabolic Medicine, Great Ormond Street Hospital, London, UK
- Great Ormond Street Hospital NIHR Biomedical Research Centre, London, UK
| | - Robin Lachmann
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
- UCL Institute of Neurology, London, UK
| | - Elaine Murphy
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
- UCL Institute of Neurology, London, UK
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7
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Dijkstra AM, van Vliet N, van Vliet D, Romani C, Huijbregts SCJ, van der Goot E, Hovens IB, van der Zee EA, Kema IP, Heiner-Fokkema MR, van Spronsen FJ. Correlations of blood and brain biochemistry in phenylketonuria: Results from the Pah-enu2 PKU mouse. Mol Genet Metab 2021; 134:250-256. [PMID: 34656426 DOI: 10.1016/j.ymgme.2021.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 06/09/2021] [Revised: 09/12/2021] [Accepted: 09/18/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND In phenylketonuria (PKU), treatment monitoring is based on frequent blood phenylalanine (Phe) measurements, as this is the predictor of neurocognitive and behavioural outcome by reflecting brain Phe concentrations and brain biochemical changes. Despite clinical studies describing the relevance of blood Phe to outcome in PKU patients, blood Phe does not explain the variance in neurocognitive and behavioural outcome completely. METHODS In a PKU mouse model we investigated 1) the relationship between plasma Phe and brain biochemistry (Brain Phe and monoaminergic neurotransmitter concentrations), and 2) whether blood non-Phe Large Neutral Amino Acids (LNAA) would be of additional value to blood Phe concentrations to explain brain biochemistry. To this purpose, we assessed blood amino acid concentrations and brain Phe as well as monoaminergic neurotransmitter levels in in 114 Pah-Enu2 mice on both B6 and BTBR backgrounds using (multiple) linear regression analyses. RESULTS Plasma Phe concentrations were strongly correlated to brain Phe concentrations, significantly negatively correlated to brain serotonin and norepinephrine concentrations and only weakly correlated to brain dopamine concentrations. From all blood markers, Phe showed the strongest correlation to brain biochemistry in PKU mice. Including non-Phe LNAA concentrations to the multiple regression model, in addition to plasma Phe, did not help explain brain biochemistry. CONCLUSION This study showed that blood Phe is still the best amino acid predictor of brain biochemistry in PKU. Nevertheless, neurocognitive and behavioural outcome cannot fully be explained by blood or brain Phe concentrations, necessitating a search for other additional parameters. TAKE-HOME MESSAGE Blood Phe is still the best amino acid predictor of brain biochemistry in PKU. Nevertheless, neurocognitive and behavioural outcome cannot fully be explained by blood or brain Phe concentrations, necessitating a search for other additional parameters.
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Affiliation(s)
- Allysa M Dijkstra
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, the Netherlands
| | - Ninke van Vliet
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, the Netherlands
| | - Danique van Vliet
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, the Netherlands
| | - Cristina Romani
- School of Life and Health Sciences, Aston University, Birmingham, UK
| | - Stephan C J Huijbregts
- Department of Clinical Child and Adolescent Studies-Neurodevelopmental Disorders, Faculty of Social Sciences, Leiden University, Leiden, the Netherlands
| | - Els van der Goot
- University of Groningen, Groningen Institute for Evolutionary Life Sciences (GELIFES), Department of Molecular Neurobiology, Groningen, the Netherlands
| | - Iris B Hovens
- University of Groningen, Groningen Institute for Evolutionary Life Sciences (GELIFES), Department of Molecular Neurobiology, Groningen, the Netherlands
| | - Eddy A van der Zee
- University of Groningen, Groningen Institute for Evolutionary Life Sciences (GELIFES), Department of Molecular Neurobiology, Groningen, the Netherlands
| | - Ido P Kema
- University of Groningen, University Medical Center Groningen, Department of laboratory Medicine, Groningen, the Netherlands
| | - M Rebecca Heiner-Fokkema
- University of Groningen, University Medical Center Groningen, Department of laboratory Medicine, Groningen, the Netherlands
| | - Francjan J van Spronsen
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, the Netherlands.
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8
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Kanufre V, Almeida MF, Barbosa CS, Carmona C, Bandeira A, Martins E, Rocha S, Guimas A, Ribeiro R, MacDonald A, Pinto A, Rocha JC. Metabolic Control of Patients with Phenylketonuria in a Portuguese Metabolic Centre Comparing Three Different Recommendations. Nutrients 2021; 13:3118. [PMID: 34578995 PMCID: PMC8469656 DOI: 10.3390/nu13093118] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 08/28/2021] [Accepted: 09/01/2021] [Indexed: 11/16/2022] Open
Abstract
Blood phenylalanine (Phe) is used as the primary marker to evaluate metabolic control. Our study aimed to describe the metabolic control of patients with phenylketonuria (PKU) comparing three different treatment recommendations (European guidelines/US guidelines/Portuguese consensus). This was a retrospective, observational, single centre study in patients with PKU collecting data on blood Phe levels from 2017. Nutritional intake data and sapropterin (BH4) prescription were collected at the last appointment of 2017. The final sample studied included 87 patients (48% females) [13 hyperphenylalaninemia; 47 mild PKU; 27 classical PKU] with a median age of 18 y (range: 1-36 y). The median number of blood Phe measurements for patients was 21 (range: 6-89). In patients aged < 12 y, the median blood Phe level was 300 μmol/L (range 168-480) and 474 μmol/L (range 156-1194) for patients ≥ 12 y. Overall, a median of 83% of blood Phe levels were within the European PKU guidelines target range. In patients aged ≥ 12 years, there was a higher median % of blood Phe levels within the European PKU guidelines target range (≥12 y: 84% vs. <12 y: 56%). In children < 12 y with classical PKU (n = 2), only 34% of blood Phe levels were within target range for all 3 guidelines and 49% with mild PKU (n = 11). Girls had better control than boys (89% vs. 66% median Phe levels within European Guidelines). Although it is clear that 50% or more patients were unable to achieve acceptable metabolic control on current treatment options, a globally agreed upper Phe target associated with optimal outcomes for age groups is necessary. More studies need to examine how clinics with dissimilar resources, different therapeutic Phe targets and frequency of monitoring relate to metabolic control.
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Affiliation(s)
- Viviane Kanufre
- Centro de Genética Médica, Centro Hospitalar Universitário do Porto (CHUPorto), 4099-028 Porto, Portugal; (V.K.); (M.F.A.); catarina-s-@hotmail.com (C.S.B.); (C.C.)
- Centro de Referência na Área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto-CHUPorto, 4099-001 Porto, Portugal; (A.B.); (E.M.); (S.R.); (A.G.); (R.R.)
- Núcleo de Ações e Pesquisa em Apoio Diagnóstico (NUPAD), School of Medicine, Federal University of Minas Gerais (UFMG), Avenida Professor Alfredo Balena, 190, Belo Horizonte 30130-100, Brazil
- Hospital das Clínicas, UFMG, Avenida Professor Alfredo Balena, 110, Santa Efigênia, Belo Horizonte 30130-100, Brazil
| | - Manuela Ferreira Almeida
- Centro de Genética Médica, Centro Hospitalar Universitário do Porto (CHUPorto), 4099-028 Porto, Portugal; (V.K.); (M.F.A.); catarina-s-@hotmail.com (C.S.B.); (C.C.)
- Centro de Referência na Área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto-CHUPorto, 4099-001 Porto, Portugal; (A.B.); (E.M.); (S.R.); (A.G.); (R.R.)
- Unit for Multidisciplinary Research in Biomedicine, Abel Salazar Institute of Biomedical Sciences, University of Porto-UMIB/ICBAS/UP, 4050-313 Porto, Portugal
| | - Catarina Sousa Barbosa
- Centro de Genética Médica, Centro Hospitalar Universitário do Porto (CHUPorto), 4099-028 Porto, Portugal; (V.K.); (M.F.A.); catarina-s-@hotmail.com (C.S.B.); (C.C.)
- Centro de Referência na Área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto-CHUPorto, 4099-001 Porto, Portugal; (A.B.); (E.M.); (S.R.); (A.G.); (R.R.)
| | - Carla Carmona
- Centro de Genética Médica, Centro Hospitalar Universitário do Porto (CHUPorto), 4099-028 Porto, Portugal; (V.K.); (M.F.A.); catarina-s-@hotmail.com (C.S.B.); (C.C.)
- Centro de Referência na Área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto-CHUPorto, 4099-001 Porto, Portugal; (A.B.); (E.M.); (S.R.); (A.G.); (R.R.)
- Unit for Multidisciplinary Research in Biomedicine, Abel Salazar Institute of Biomedical Sciences, University of Porto-UMIB/ICBAS/UP, 4050-313 Porto, Portugal
| | - Anabela Bandeira
- Centro de Referência na Área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto-CHUPorto, 4099-001 Porto, Portugal; (A.B.); (E.M.); (S.R.); (A.G.); (R.R.)
| | - Esmeralda Martins
- Centro de Referência na Área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto-CHUPorto, 4099-001 Porto, Portugal; (A.B.); (E.M.); (S.R.); (A.G.); (R.R.)
- Unit for Multidisciplinary Research in Biomedicine, Abel Salazar Institute of Biomedical Sciences, University of Porto-UMIB/ICBAS/UP, 4050-313 Porto, Portugal
| | - Sara Rocha
- Centro de Referência na Área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto-CHUPorto, 4099-001 Porto, Portugal; (A.B.); (E.M.); (S.R.); (A.G.); (R.R.)
| | - Arlindo Guimas
- Centro de Referência na Área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto-CHUPorto, 4099-001 Porto, Portugal; (A.B.); (E.M.); (S.R.); (A.G.); (R.R.)
| | - Rosa Ribeiro
- Centro de Referência na Área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto-CHUPorto, 4099-001 Porto, Portugal; (A.B.); (E.M.); (S.R.); (A.G.); (R.R.)
| | - Anita MacDonald
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (A.M.); (A.P.)
| | - Alex Pinto
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (A.M.); (A.P.)
| | - Júlio César Rocha
- Centro de Genética Médica, Centro Hospitalar Universitário do Porto (CHUPorto), 4099-028 Porto, Portugal; (V.K.); (M.F.A.); catarina-s-@hotmail.com (C.S.B.); (C.C.)
- Centro de Referência na Área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto-CHUPorto, 4099-001 Porto, Portugal; (A.B.); (E.M.); (S.R.); (A.G.); (R.R.)
- Nutrition & Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Campo Mártires da Pátria, 130, 1169-056 Lisbon, Portugal
- Centre for Health Technology and Services Research (CINTESIS), 4200-450 Porto, Portugal
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9
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Puurunen MK, Vockley J, Searle SL, Sacharow SJ, Phillips JA, Denney WS, Goodlett BD, Wagner DA, Blankstein L, Castillo MJ, Charbonneau MR, Isabella VM, Sethuraman VV, Riese RJ, Kurtz CB, Brennan AM. Safety and pharmacodynamics of an engineered E. coli Nissle for the treatment of phenylketonuria: a first-in-human phase 1/2a study. Nat Metab 2021; 3:1125-1132. [PMID: 34294923 DOI: 10.1038/s42255-021-00430-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [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: 02/17/2021] [Accepted: 06/23/2021] [Indexed: 01/01/2023]
Abstract
Phenylketonuria (PKU) is a rare disease caused by biallelic mutations in the PAH gene that result in an inability to convert phenylalanine (Phe) to tyrosine, elevated blood Phe levels and severe neurological complications if untreated. Most patients are unable to adhere to the protein-restricted diet, and thus do not achieve target blood Phe levels. We engineered a strain of E. coli Nissle 1917, designated SYNB1618, through insertion of the genes encoding phenylalanine ammonia lyase and L-amino acid deaminase into the genome, which allow for bacterial consumption of Phe within the gastrointestinal tract. SYNB1618 was studied in a phase 1/2a randomized, placebo-controlled, double-blind, multi-centre, in-patient study ( NCT03516487 ) in adult healthy volunteers (n = 56) and patients with PKU and blood Phe level ≥600 mmol l-1 (n = 14). Participants were randomized to receive a single dose of SYNB1618 or placebo (part 1) or up to three times per day for up to 7 days (part 2). The primary outcome of this study was safety and tolerability, and the secondary outcome was microbial kinetics. A D5-Phe tracer (15 mg kg-1) was used to study exploratory pharmacodynamic effects. SYNB1618 was safe and well tolerated with a maximum tolerated dose of 2 × 1011 colony-forming units. Adverse events were mostly gastrointestinal and of mild to moderate severity. All participants cleared the bacteria within 4 days of the last dose. Dose-responsive increases in strain-specific Phe metabolites in plasma (trans-cinnamic acid) and urine (hippuric acid) were observed, providing a proof of mechanism for the potential to use engineered bacteria in the treatment of rare metabolic disorders.
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Affiliation(s)
| | - Jerry Vockley
- University of Pittsburgh, Pittsburgh, PA, USA
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | | | - Stephanie J Sacharow
- Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | | | - Benjamin D Goodlett
- Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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10
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Daly A, Högler W, Crabtree N, Shaw N, Evans S, Pinto A, Jackson R, Ashmore C, Rocha JC, Strauss BJ, Wilcox G, Fraser WD, Tang JCY, MacDonald A. A Three-Year Longitudinal Study Comparing Bone Mass, Density, and Geometry Measured by DXA, pQCT, and Bone Turnover Markers in Children with PKU Taking L-Amino Acid or Glycomacropeptide Protein Substitutes. Nutrients 2021; 13:nu13062075. [PMID: 34204378 PMCID: PMC8233747 DOI: 10.3390/nu13062075] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 06/09/2021] [Indexed: 12/20/2022] Open
Abstract
In patients with phenylketonuria (PKU), treated by diet therapy only, evidence suggests that areal bone mineral density (BMDa) is within the normal clinical reference range but is below the population norm. Aims: To study longitudinal bone density, mass, and geometry over 36 months in children with PKU taking either amino acid (L-AA) or casein glycomacropeptide substitutes (CGMP-AA) as their main protein source. Methodology: A total of 48 subjects completed the study, 19 subjects in the L-AA group (median age 11.1, range 5–16 years) and 29 subjects in the CGMP-AA group (median age 8.3, range 5–16 years). The CGMP-AA was further divided into two groups, CGMP100 (median age 9.2, range 5–16 years) (n = 13), children taking CGMP-AA only and CGMP50 (median age 7.3, range 5–15 years) (n = 16), children taking a combination of CGMP-AA and L-AA. Dual X-ray absorptiometry (DXA) was measured at enrolment and 36 months, peripheral quantitative computer tomography (pQCT) at 36 months only, and serum blood and urine bone turnover markers (BTM) and blood bone biochemistry at enrolment, 6, 12, and 36 months. Results: No statistically significant differences were found between the three groups for DXA outcome parameters, i.e., BMDa (L2–L4 BMDa g/cm2), bone mineral apparent density (L2–L4 BMAD g/cm3) and total body less head BMDa (TBLH g/cm2). All blood biochemistry markers were within the reference ranges, and BTM showed active bone turnover with a trend for BTM to decrease with increasing age. Conclusions: Bone density was clinically normal, although the median z scores were below the population mean. BTM showed active bone turnover and blood biochemistry was within the reference ranges. There appeared to be no advantage to bone density, mass, or geometry from taking a macropeptide-based protein substitute as compared with L-AAs.
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Affiliation(s)
- Anne Daly
- Birmingham Women’s and Children’s Hospital, NHS Foundation Trust, Birmingham B4 6NH, UK; (N.C.); (N.S.); (S.E.); (A.P.); (C.A.); (A.M.)
- Correspondence:
| | - Wolfgang Högler
- Department of Paediatrics and Adolescent Medicine, Johannes Kepler University, Kepler University Hospital, Krankenhausstraße 26-30, 4020 Linz, Austria;
| | - Nicola Crabtree
- Birmingham Women’s and Children’s Hospital, NHS Foundation Trust, Birmingham B4 6NH, UK; (N.C.); (N.S.); (S.E.); (A.P.); (C.A.); (A.M.)
| | - Nick Shaw
- Birmingham Women’s and Children’s Hospital, NHS Foundation Trust, Birmingham B4 6NH, UK; (N.C.); (N.S.); (S.E.); (A.P.); (C.A.); (A.M.)
| | - Sharon Evans
- Birmingham Women’s and Children’s Hospital, NHS Foundation Trust, Birmingham B4 6NH, UK; (N.C.); (N.S.); (S.E.); (A.P.); (C.A.); (A.M.)
| | - Alex Pinto
- Birmingham Women’s and Children’s Hospital, NHS Foundation Trust, Birmingham B4 6NH, UK; (N.C.); (N.S.); (S.E.); (A.P.); (C.A.); (A.M.)
| | - Richard Jackson
- Liverpool Clinical Trials Centre, University of Liverpool, Brownlow Hill, Liverpool L69 3GL, UK;
| | - Catherine Ashmore
- Birmingham Women’s and Children’s Hospital, NHS Foundation Trust, Birmingham B4 6NH, UK; (N.C.); (N.S.); (S.E.); (A.P.); (C.A.); (A.M.)
| | - Júlio C. Rocha
- Nutrition and Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, 1169-056 Lisboa, Portugal;
- Centre for Health and Technology and Services Research (CINTESIS), 4200-450 Porto, Portugal
| | - Boyd J. Strauss
- School of Medical Sciences, Faculty of Biology, Medicine and Health Sciences, University of Manchester, Manchester M13 9PL, UK; (B.J.S.); (G.W.)
- School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne 3800, Australia
| | - Gisela Wilcox
- School of Medical Sciences, Faculty of Biology, Medicine and Health Sciences, University of Manchester, Manchester M13 9PL, UK; (B.J.S.); (G.W.)
- The Mark Holland Metabolic Unit, Salford Royal Foundation NHS Trust, Ladywell NW2, Salford, Manchester M6 8HD, UK
| | - William D. Fraser
- BioAnalytical Facility, BCRE Builiding University or East Anglia, Norwich NR4 7TJ, UK; (W.D.F.); (J.C.Y.T.)
| | - Jonathan C. Y. Tang
- BioAnalytical Facility, BCRE Builiding University or East Anglia, Norwich NR4 7TJ, UK; (W.D.F.); (J.C.Y.T.)
- Departments of Clinical Biochemistry and Endocrinology, Norfolk and Norwich University Hospitals Trust, Norwich NR4 7UY, UK
| | - Anita MacDonald
- Birmingham Women’s and Children’s Hospital, NHS Foundation Trust, Birmingham B4 6NH, UK; (N.C.); (N.S.); (S.E.); (A.P.); (C.A.); (A.M.)
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11
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Evers RAF, van Wegberg AMJ, Ahring K, Beblo S, Bélanger-Quintana A, Bosch AM, Burlina A, Campistol J, Coskun T, Feillet F, Giżewska M, Huijbregts SCJ, Kearney S, Langeveld M, Leuzzi V, Maillot F, Muntau AC, Rocha JC, Romani C, Trefz FK, MacDonald A, van Spronsen FJ. Defining tetrahydrobiopterin responsiveness in phenylketonuria: Survey results from 38 countries. Mol Genet Metab 2021; 132:215-219. [PMID: 33610470 DOI: 10.1016/j.ymgme.2021.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/28/2021] [Accepted: 01/29/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND A subset of patients with phenylketonuria benefit from treatment with tetrahydrobiopterin (BH4), although there is no consensus on the definition of BH4 responsiveness. The aim of this study therefore was to gain insight into the definitions of long-term BH4 responsiveness being used around the world. METHODS We performed a web-based survey targeting healthcare professionals involved in the treatment of PKU patients. Data were analysed according to geographical region (Europe, USA/Canada, other). RESULTS We analysed 166 responses. Long-term BH4 responsiveness was commonly defined using natural protein tolerance (95.6%), improvement of metabolic control (73.5%) and increase in quality of life (48.2%). When a specific value for a reduction in phenylalanine concentrations was reported (n = 89), 30% and 20% were most frequently used as cut-off values (76% and 19% of respondents, respectively). When a specific relative increase in natural protein tolerance was used to define long-term BH4 responsiveness (n = 71), respondents most commonly reported cut-off values of 30% and 100% (28% of respondents in both cases). Respondents from USA/Canada (n = 50) generally used less strict cut-off values compared to Europe (n = 96). Furthermore, respondents working within the same center answered differently. CONCLUSION The results of this study suggest a very heterogeneous situation on the topic of defining long-term BH4 responsiveness, not only at a worldwide level but also within centers. Developing a strong evidence- and consensus-based definition would improve the quality of BH4 treatment.
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Affiliation(s)
- R A F Evers
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Division of Metabolic Diseases, the Netherlands
| | - A M J van Wegberg
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Division of Metabolic Diseases, the Netherlands
| | - K Ahring
- Department of PKU, Copenhagen University Hospital, Denmark
| | - S Beblo
- Center for Pediatric Research Leipzig, Department of Women and Child Health, Hospital for Children and Adolescents, University Hospitals, Germany
| | - A Bélanger-Quintana
- Metabolic Diseases Unit, Department of Pediatrics, Hospital Ramon y Cajal, Madrid, Spain
| | - A M Bosch
- Department of Pediatrics, Division of Metabolic Disorders, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - A Burlina
- Division of Inherited Metabolic Diseases, Department of Integrated Diagnostics, University Hospital of Padova, Padova, Italy
| | - J Campistol
- Neuropaediatrics Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - T Coskun
- Hacettepe University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Nutrition & Metabolism, Hacettepe, Ankara, Turkey
| | - F Feillet
- Inborn Errors of Metabolism, Pediatric unit, University Hospital of Nancy, INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Nancy, France
| | - M Giżewska
- Department of Pediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology of the Developmental Age, Pomeranian Medical University, Szczecin, Poland
| | - S C J Huijbregts
- Department of Clinical Child and Adolescent Studies-Neurodevelopmental Disorders, Faculty of Social Sciences, Leiden University, Leiden, Netherlands
| | - S Kearney
- Clinical Psychology Department, Birmingham Children's Hospital, Birmingham, UK
| | - M Langeveld
- Department of Endocrinology and Metabolism, Amterdam UMC, University of Amsterdam, AZ, Amsterdam, the Netherlands
| | - V Leuzzi
- Department of Human Neuroscience, Unit of Child Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - F Maillot
- Department of Internal Medicine, CHRU de Tours, Université de Tours, Tours, France
| | - A C Muntau
- University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J C Rocha
- Centro de Referência na área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto - CHUP, Porto, Portugal; Centre for Health Technology and Services Research (CINTESIS), Portugal; Nutrition & Metabolism, Nova Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal
| | - C Romani
- School of Life and Health Sciences, Aston University, Birmingham, UK
| | - F K Trefz
- University Children's Hospital, Dietmar-Hoppe Metabolic Centre, Heidelberg, Germany
| | - A MacDonald
- Dietetic Department, Birmingham Children's Hospital, Birmingham, UK
| | - F J van Spronsen
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Division of Metabolic Diseases, the Netherlands.
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12
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Jeanjean LC, Duval F, Foucher JR, Gendrault C. Neuroendocrine Response to Apomorphine After Tetrahydrobiopterin Use in a Depressed Teenager With Mild Hyperphenylalaninemia: A Case Report. J Clin Psychopharmacol 2021; 40:414-416. [PMID: 32639296 DOI: 10.1097/jcp.0000000000001241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Daly A, Evans S, Pinto A, Ashmore C, MacDonald A. Protein Substitutes in PKU; Their Historical Evolution. Nutrients 2021; 13:484. [PMID: 33540516 PMCID: PMC7912909 DOI: 10.3390/nu13020484] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 12/29/2022] Open
Abstract
Protein substitutes developed for phenylketonuria (PKU) are a synthetic source of protein commonly based on L-amino acids. They are essential in the treatment of phenylketonuria (PKU) and other amino acid disorders, allowing the antagonistic amino acid to be removed but with the safe provision of all other amino acids necessary for maintaining normal physiological function. They were first formulated by a chemist and used experimentally on a 2-year-old girl with PKU and their nutritional formulations and design have improved over time. Since 2008, a bioactive macropeptide has been used as a base for protein substitutes in PKU, with potential benefits of improved bone and gut health, nitrogen retention, and blood phenylalanine control. In 2018, animal studies showed that physiomimic technology coating the amino acids with a polymer allows a slow release of amino acids with an improved physiological profile. History has shown that in PKU, the protein substitute's efficacy is determined by its nutritional profile, amino acid composition, dose, timing, distribution, and an adequate energy intake. Protein substitutes are often given little importance, yet their pharmacological actions and clinical benefit are pivotal when managing PKU.
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Affiliation(s)
- Anne Daly
- Birmingham Women’s and Children’s Hospital, NHS Foundation Trust, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
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14
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Waisbren S, Burton BK, Feigenbaum A, Konczal LL, Lilienstein J, McCandless SE, Rowell R, Sanchez-Valle A, Whitehall KB, Longo N. Long-term preservation of intellectual functioning in sapropterin-treated infants and young children with phenylketonuria: A seven-year analysis. Mol Genet Metab 2021; 132:119-127. [PMID: 33485801 PMCID: PMC8684368 DOI: 10.1016/j.ymgme.2021.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/04/2021] [Accepted: 01/04/2021] [Indexed: 11/19/2022]
Abstract
Sapropterin dihydrochloride has been approved for the treatment of hyperphenylalaninemia in infants and young children with phenylketonuria (PKU). Sapropterin can reduce phenylalanine (Phe) levels in tetrahydrobiopterin (BH4)-responsive patients, potentially preventing the intellectual impairment caused by elevated Phe levels. The long-term effect of sapropterin on intellectual functioning was assessed using the Full-Scale Intelligence Quotient (FSIQ) in 62 children who began treatment before the age of 6 years. Over each 2-year interval, the estimate of mean change in FSIQ was -0.5768 with a lower limit of the 95% confidence interval (CI) of -1.60. At the end of the follow-up period (Year 7), the least squares mean estimate of the change in FSIQ from baseline was 1.14 with a lower limit of the 95% CI of -3.53. These lower limits were both within the clinically expected variation of 5 points. During the whole study period, mean blood Phe levels remained within the American College of Medical Genetics (ACMG) target range of 120-360 μmol/L. In addition, height, weight, and head circumference were maintained within normal ranges throughout follow-up, as defined by growth charts from the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) for children below and above the age of 24 months, respectively. All patients (n = 65) enrolled in this study experienced at least one adverse event, as expected from previous studies. In conclusion, long-term use of sapropterin in individuals with PKU helps to control blood Phe, preserve intellectual functioning, and maintain normal growth in BH4-responsive children who initiated treatment between the ages of 0 to 6 years.
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Affiliation(s)
- Susan Waisbren
- Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Barbara K Burton
- Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Annette Feigenbaum
- The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Laura L Konczal
- Center for Human Genetics, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | | | - Shawn E McCandless
- Section of Genetics and Metabolism, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
| | | | | | | | - Nicola Longo
- Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA.
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15
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Abstract
BACKGROUND Phenylketonuria is an inherited disease for which the main treatment is the dietary restriction of the amino acid phenylalanine. The diet has to be initiated in the neonatal period to prevent or reduce mental handicap. However, the diet is very restrictive and unpalatable and can be difficult to follow. A deficiency of the amino acid tyrosine has been suggested as a cause of some of the neuropsychological problems exhibited in phenylketonuria. Therefore, this review aims to assess the efficacy of tyrosine supplementation for phenylketonuria. This is an update of previously published versions of this review. OBJECTIVES To assess the effects of tyrosine supplementation alongside or instead of a phenylalanine-restricted diet for people with phenylketonuria, who commenced on diet at diagnosis and either continued on the diet or relaxed the diet later in life. To assess the evidence that tyrosine supplementation alongside, or instead of a phenylalanine-restricted diet improves intelligence, neuropsychological performance, growth and nutritional status, mortality rate and quality of life. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Trials Register which is comprised of references identified from comprehensive electronic database searches, handsearches of relevant journals and abstract books of conference proceedings. Additional studies were identified from handsearches of the Journal of Inherited Metabolic Disease (from inception in 1978 to 1998). The manufacturers of prescribable dietary products used in the treatment of phenylketonuria were also contacted for further references. Date of the most recent search of the Group's Inborn Errors of Metabolism Trials Register: 07 December 2020. SELECTION CRITERIA All randomised or quasi-randomised trials investigating the use of tyrosine supplementation versus placebo in people with phenylketonuria in addition to, or instead of, a phenylalanine-restricted diet. People treated for maternal phenylketonuria were excluded. DATA COLLECTION AND ANALYSIS Two authors independently assessed the trial eligibility, methodological quality and extracted the data. MAIN RESULTS Six trials were found, of which three trials reporting the results of a total of 56 participants, were suitable for inclusion in the review. The blood tyrosine concentrations were significantly higher in the participants receiving tyrosine supplements than those in the placebo group, mean difference 23.46 (95% confidence interval 12.87 to 34.05). No significant differences were found between any of the other outcomes measured. The trials were assessed as having a low to moderate risk of bias across several domains. AUTHORS' CONCLUSIONS From the available evidence no recommendations can be made about whether tyrosine supplementation should be introduced into routine clinical practice. Further randomised controlled studies are required to provide more evidence. However, given this is not an active area of research, we have no plans to update this review in the future.
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Affiliation(s)
- Tracey Remmington
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Sherie Smith
- Division of Child Health, Obstetrics & Gynaecology (COG), School of Medicine, University of Nottingham, Nottingham, UK
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16
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Manzoni F, Salvatici E, Burlina A, Andrews A, Pasquali M, Longo N. Retrospective analysis of 19 patients with 6-Pyruvoyl Tetrahydropterin Synthase Deficiency: Prolactin levels inversely correlate with growth. Mol Genet Metab 2020; 131:380-389. [PMID: 33234470 PMCID: PMC7749858 DOI: 10.1016/j.ymgme.2020.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 09/11/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pyruvoyl Tetrahydropterin Synthase (PTPS) Deficiency is the most common form of BH4 deficiency resulting in hyperphenylalaninemia. It can have variable clinical severity and there is limited information on the clinical presentation, natural history and effectiveness of newborn screening for this condition. METHODS Retrospective data (growth and clinical parameters, biochemical and genetic testing results, treatment) were collected from 19 patients with PTPS deficiency in different centers, to evaluate biochemical and clinical outcomes. Descriptive statistics was used for qualitative variables, while linear regression analysis was used to correlate quantitative variables. RESULTS Patients with PTPS deficiency had an increased incidence of prematurity (4/18) with an average gestational age only mildly reduced (37.8 ± 2.4 weeks) and low birth weight (-1.14 ± 0.97 SD below that predicted for gestational age). With time, weight and height approached normal. VALUES All patients were identified by newborn screening for an elevated phenylalanine level. However, phenylalanine levels were normal in two whose testing was performed at or before 24 h of age. Sapropterin dihydrochloride treatment normalized phenylalanine levels. Molecular testing identified novel variants in the PTS gene, some of which present in more than one affected family. The neurotransmitter derivatives 5-hydroxyindoleacetic acid (5HIAA) and homovanillic acid (HVA) in the CSF were decreased in most cases except in 2 families with the peripheral form of PTPS deficiency. With time, HVA and 5HIAA became abnormally low in two of these patients requiring therapy. Prolactin (whose secretion is inhibited by dopamine) levels were elevated in several patients with PTPS deficiency and inversely correlated with the z-scores for height (p < 0.01) and weight (p < 0.05). Most patients with PTPS deficiency had delayed development early in life, improving around school age with IQs mostly in the normal range, with a small decline in older individuals. From a neurological standpoint, most patients had normal brain MRI and minor EEG anomalies, although some had persistent neurological symptoms. DISCUSSION Patients with PTPS deficiency have not only an increased incidence of prematurity, but also decreased birth weight when corrected for gestational age. Hyperphenylalaninemia can be absent in the first day of life. Therapy with sapropterin dihydrochloride normalizes phenylalanine levels and neurotransmitter precursors can improve CSF neurotransmitter metabolites levels. Insufficient dopaminergic stimulation (as seen from elevated prolactin) might result in decreased height in patients with PTPS deficiency. Despite early delays in development, many patients can achieve independence in adult life, with usually normal neuroimaging and EEG.
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Affiliation(s)
- Francesca Manzoni
- Division of Medical Genetics/Pediatrics, University of Utah, Salt Lake City, UT, USA; Clinical Department of Neuropsychiatry, San Paolo Hospital, University of Milan, Milan, Italy; Division of Inherited Metabolic Diseases, Department of Diagnostic Services, University Hospital, Padua, Italy
| | - Elisabetta Salvatici
- Clinical Department of Pediatrics, San Paolo Hospital, University of Milan, Milan, Italy
| | - Alberto Burlina
- Division of Inherited Metabolic Diseases, Department of Diagnostic Services, University Hospital, Padua, Italy
| | - Ashley Andrews
- Division of Medical Genetics/Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Marzia Pasquali
- Division of Medical Genetics/Pediatrics, University of Utah, Salt Lake City, UT, USA; ARUP Laboratories, Salt Lake City, UT, USA; Department of Pathology, University of Utah, Salt Lake City, UT, USA
| | - Nicola Longo
- Division of Medical Genetics/Pediatrics, University of Utah, Salt Lake City, UT, USA; ARUP Laboratories, Salt Lake City, UT, USA; Department of Pathology, University of Utah, Salt Lake City, UT, USA..
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17
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Yan T, Zhang T, Mu W, Qi Y, Guo S, Hu N, Zhao W, Zhang S, Wang Q, Shi L, Liu L. Ionizing radiation induces BH 4 deficiency by downregulating GTP-cyclohydrolase 1, a novel target for preventing and treating radiation enteritis. Biochem Pharmacol 2020; 180:114102. [PMID: 32562786 DOI: 10.1016/j.bcp.2020.114102] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/22/2020] [Accepted: 06/15/2020] [Indexed: 01/22/2023]
Abstract
Radiation enteritis (RE) is a common side effect after radiotherapy for abdominal cancer. RE pathogenesis is complicated, with no drugs available for prevention or treatments. Intestinal ischemia is a key factor in the occurrence and development of enteritis. The effect of ionizing radiation (IR) on intestinal ischemia is unknown. Deficiency of tetrahydrobiopterin (BH4) produced by GTP-cyclohydrolase 1 (Gch1) is important in ischemic diseases. This study focused on the relationship of Gch1/BH4 between intestinal ischemia in radiation enteritis. BH4 levels were analyzed by high-performance liquid chromatography in humans and rats after radiotherapy. Intestinal blood perfusion was measured by laser doppler flow imaging. Vascular ring tests determined the diastolic functions of rat mesenteric arteries. Gene, protein, and immunohistochemical staining experiments and inhibitor interventions were used to investigate Gch1 and endothelial NOS (eNOS) in rat mesenteric arteries and endothelial cells. The results showed that IR decreased BH4 levels in patients and rats after radiotherapy and decreased intestinal blood perfusion in rats. The degree of change in intestinal ischemia was consistent with intestinal villus injury. Gch1 mRNA and protein levels and nitric oxide (NO) production significantly decreased, while eNOS uncoupling in arterial and vascular endothelial cells strongly increased. BH4 supplementation improved eNOS uncoupling and NO levels in vascular endothelia after IR. The results of this study showed that downregulation of Gch1 in intestinal blood vessels after IR is an important target in RE. BH4 supplementation may prevent intestinal ischemia and improve vascular endothelial function after IR. These findings have clinical significance for the prevention and treatment of RE.
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Affiliation(s)
- Tao Yan
- Department of Pharmacy, The Second Affiliated Hospital of Air Force Medical University, Xi'an, PR China
| | - Tian Zhang
- Department of Pharmacy, The Second Affiliated Hospital of Air Force Medical University, Xi'an, PR China
| | - Wei Mu
- Department of Pharmacy, The Second Affiliated Hospital of Air Force Medical University, Xi'an, PR China
| | - Yuhong Qi
- Department of Radiotherapy, The Second Affiliated Hospital of Air Force Medical University, Xi'an, PR China
| | - Shun Guo
- Department of Pharmacy, The Second Affiliated Hospital of Air Force Medical University, Xi'an, PR China
| | - Na Hu
- Department of Pharmacy, The Second Affiliated Hospital of Air Force Medical University, Xi'an, PR China
| | - Weihe Zhao
- Department of Radiotherapy, The Second Affiliated Hospital of Air Force Medical University, Xi'an, PR China
| | - Song Zhang
- Department of Pharmacy, The Second Affiliated Hospital of Air Force Medical University, Xi'an, PR China
| | - Qinhui Wang
- Department of Pharmacy, The Second Affiliated Hospital of Air Force Medical University, Xi'an, PR China
| | - Lei Shi
- Department of Pharmacy, The Second Affiliated Hospital of Air Force Medical University, Xi'an, PR China.
| | - Linna Liu
- Department of Pharmacy, The Second Affiliated Hospital of Air Force Medical University, Xi'an, PR China.
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18
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Abstract
Phenylketonuria (PKU) is the most common inborn error of amino acids metabolism. PKU management aims to keep as soon as possible blood phenylalanine (Phe), a non-acutely neurotoxic metabolite, within safe ranges through a dietary Phe restriction tailored to individual dietary Phe tolerance. Information on initial neonatal management of PKU, when Phe tolerance is still unknown, is scanty. We reviewed the metabolic data from 304 patients with PAH deficiency detected at newborn screening within the last 37 years. In keeping with the general neonatal management of intoxication-type inborn errors of metabolism, initial management consisted in a Phe wash-out through the exclusive administration of normocaloric Phe-free formulas until normalization of blood Phe. Based on genotype and Phe tolerance assessed at follow-up, 55 patients had classic PKU (18%), 50 mild PKU (17%), and 199 non-PKU hyperphenylalaninemia (HPA) (65%). The duration of Phe wash-out amounted to 7 ± 2 days in classic PKU, 4 ± 2 days in mild PKU, and < 24 h in non-PKU HPA (p < 0.001). After the wash-out, dietary Phe re-introduction and its upwardly titration allowed the assessment of individual metabolic phenotype. During the first 6 years of life, Phe tolerance was stable in classic PKU (~ 200 mg/day) but increased in milder forms, allowing unrestricted diet in non-PKU HPA. Neonatal Phe wash-out in PKU ensures the earliest correction of HPA. This metabolic reset also facilitates the prompt definition of individual Phe tolerance, allowing anticipation of dietary personalization and optimization of longitudinal metabolic control.
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Affiliation(s)
- Francesco Porta
- Department of Pediatrics, AOU Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy.
- Department of Pediatrics, University of Torino, Piazza Polonia 94, Turin, 10126, Italy.
| | - Alberto Ponzone
- Department of Pediatrics, AOU Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Marco Spada
- Department of Pediatrics, AOU Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
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19
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Boulet L, Besson G, Van Noolen L, Faure P, Maillot F, Corne C. Tryptophan metabolism in phenylketonuria: A French adult cohort study. J Inherit Metab Dis 2020; 43:944-951. [PMID: 32392388 DOI: 10.1002/jimd.12250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 04/23/2020] [Accepted: 05/08/2020] [Indexed: 11/09/2022]
Abstract
Many similarities between tryptophan (Trp) and phenylalanine (Phe) metabolisms exist. It is possible that a modification of Trp metabolism might be seen in phenylketonuria (PKU). As some of these metabolites have neuroactive properties, they should be consider in neurological impairment seen in this pathology and not totally explained by blood Phe concentrations. One hundred and fifty-one adult PKU patients (mean age 26.8 years) were included for this study. Plasma Trp, kynurenine (KYN), 3-hydroxykynurenic acid (3HK), and kynurenic acid (KA) were analyzed by liquid chromatography coupled with tandem mass spectrometry. KYN and 3HK were significantly lower in PKU patients compared to general population (P < .0001), and KA was significantly enhanced is this population (P = .009). Furthermore, 3HK concentration was significantly different between PKU patients underwent controlled low-Phe diet compared to PKU patients without this diet (P = .0016). In PKU patients with diet, taking AA substitute enable higher plasma 3HK concentration than without (P = .0008) but still not reaching general population level (P < .0001). Although further study has to be done, it is clear that Trp metabolism is modified in adult PKU patients. An exploration of complete Trp metabolism, and not only Trp concentration, is needed in PKU population, but also in other inborn error of metabolism treated with hypoprotidic diet.
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Affiliation(s)
- Lysiane Boulet
- Laboratoire des Maladies Héréditaires du Métabolisme, Service de Biochimie, Biologie Moléculaire, Toxicologie Environnementale, CHU de Grenoble-Alpes site Nord- Institut de Biologie et de Pathologie, La Tronche, France
| | - Gérard Besson
- Service de Neurologie Générale, CHU de Grenoble-Alpes site Nord, La Tronche, France
| | - Laetitia Van Noolen
- Laboratoire des Maladies Héréditaires du Métabolisme, Service de Biochimie, Biologie Moléculaire, Toxicologie Environnementale, CHU de Grenoble-Alpes site Nord- Institut de Biologie et de Pathologie, La Tronche, France
| | - Patrice Faure
- Service de Biochimie, Biologie Moléculaire, Toxicologie Environnementale, CHU de Grenoble-Alpes site Nord- Institut de Biologie et de Pathologie, La Tronche, France
| | - François Maillot
- CHRU de Tours, médecine interne, université de Tours, INSERM 1253, Tours, France
| | - Christelle Corne
- Laboratoire des Maladies Héréditaires du Métabolisme, Service de Biochimie, Biologie Moléculaire, Toxicologie Environnementale, CHU de Grenoble-Alpes site Nord- Institut de Biologie et de Pathologie, La Tronche, France
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20
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Sumanszki C, Kovacs K, Karvaly GB, Kiss E, Simon E, Patocs A, Toth M, Komka Z, Reismann P. Metabolic and catecholamine response to sympathetic stimulation in early-treated adult male patients with phenylketonuria. Hormones (Athens) 2020; 19:395-402. [PMID: 31993977 PMCID: PMC7426284 DOI: 10.1007/s42000-020-00176-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/22/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE Defective function of phenylalanine hydroxylase in phenylketonuria (PKU) results in the accumulation of phenylalanine (Phe) and the reduction of tyrosine (Tyr) in the blood, interfering in the normal development and function of organs and tissues in the body. Tyr is the precursor of catecholamines, secreted in response to stress by the adrenal medulla and paraganglia. The aim of this study was to evaluate plasma catecholamine and amino acid response to an escalating series of sympathetic stress tests in PKU patients. METHODS Twelve males with classical PKU (aged 18-41 years) and ten healthy male controls were included in this study. The subjects were exposed to three different sympathetic stress stimulations: cold pressor, isometric handgrip, and peak treadmill tests to exhaustion. Physiological, metabolic, and hormonal changes were determined. RESULTS Aerobic capacity (VO2max) was significantly lower in the PKU group (p = 0.018); however, relative VO2max was similar in the two groups during the spiroergometric test. No significant differences in norepinephrine or in epinephrine response were found between the two groups during the different stimulation tests. Blood Phe increased significantly in the PKU group compared with controls (p = 0.027) during the spiroergometric test, while Tyr levels remained stable in both groups. CONCLUSION PKU itself might not influence stress-induced catecholamine changes. Only strenuous exercise increased blood Phe levels in PKU subjects.
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Affiliation(s)
- Csaba Sumanszki
- 2nd Department of Internal Medicine, Faculty of Medicine, Semmelweis University, Szentkirályi u. 46, Budapest, 1088 Hungary
| | - Krisztian Kovacs
- Department of Laboratory Medicine, Semmelweis University, Budapest, Hungary
| | | | - Erika Kiss
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Erika Simon
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Attila Patocs
- Molecular Medicine Research Group, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
- “Lendület” Hereditary Endocrine Tumours Research Group, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Miklos Toth
- Department of Health Sciences and Sport Medicine, University of Physical Education, Budapest, Hungary
| | - Zsolt Komka
- Department of Health Sciences and Sport Medicine, University of Physical Education, Budapest, Hungary
| | - Peter Reismann
- 2nd Department of Internal Medicine, Faculty of Medicine, Semmelweis University, Szentkirályi u. 46, Budapest, 1088 Hungary
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21
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Daly A, Evans S, Pinto A, Jackson R, Ashmore C, Rocha JC, MacDonald A. Preliminary Investigation to Review If a Glycomacropeptide Compared to L-Amino Acid Protein Substitute Alters the Pre- and Postprandial Amino Acid Profile in Children with Phenylketonuria. Nutrients 2020; 12:E2443. [PMID: 32823853 PMCID: PMC7468934 DOI: 10.3390/nu12082443] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 08/11/2020] [Accepted: 08/11/2020] [Indexed: 12/24/2022] Open
Abstract
In Phenylketonuria (PKU), the peptide structure of the protein substitute (PS), casein glycomacropeptide (CGMP), is supplemented with amino acids (CGMP-AA). CGMP may slow the rate of amino acid (AA) absorption compared with traditional phenylalanine-free amino acids (Phe-free AA), which may improve nitrogen utilization, decrease urea production, and alter insulin response. AIM In children with PKU, to compare pre and postprandial AA concentrations when taking one of three PS's: Phe-free AA, CGMP-AA 1 or 2. METHODS 43 children (24 boys, 19 girls), median age 9 years (range 5-16 years) were studied; 11 took CGMP-AA1, 18 CGMP-AA2, and 14 Phe-free AA. Early morning fasting pre and 2 h postprandial blood samples were collected for quantitative AA on one occasion. A breakfast with allocated 20 g protein equivalent from PS was given post fasting blood sample. RESULTS There was a significant increase in postprandial AA for all individual AAs with all three PS. Postprandial AA histidine (p < 0.001), leucine (p < 0.001), and tyrosine (p < 0.001) were higher in CGMP-AA2 than CGMP-AA1, and leucine (p < 0.001), threonine (p < 0.001), and tyrosine (p = 0.003) higher in GCMP-AA2 than Phe-free AA. This was reflective of the AA composition of the three different PS's. CONCLUSIONS In PKU, the AA composition of CGMP-AA influences 2 h postprandial AA composition, suggesting that a PS derived from CGMP-AA may be absorbed similarly to Phe-free AA, but this requires further investigation.
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Affiliation(s)
- Anne Daly
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
| | - Sharon Evans
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
| | - Alex Pinto
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
| | - Richard Jackson
- Liverpool Clinical Trials Centre, University of Liverpool, Brownlow Hill, Liverpool L69 3GL, UK;
| | - Catherine Ashmore
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
| | - Júlio César Rocha
- Nutrition and Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, 1169-056 Lisboa, Portugal;
- Centre for Health Technology and Services Research (CINTESIS), 4200-450 Porto, Portugal
| | - Anita MacDonald
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
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22
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Hillert A, Anikster Y, Belanger-Quintana A, Burlina A, Burton BK, Carducci C, Chiesa AE, Christodoulou J, Đorđević M, Desviat LR, Eliyahu A, Evers RAF, Fajkusova L, Feillet F, Bonfim-Freitas PE, Giżewska M, Gundorova P, Karall D, Kneller K, Kutsev SI, Leuzzi V, Levy HL, Lichter-Konecki U, Muntau AC, Namour F, Oltarzewski M, Paras A, Perez B, Polak E, Polyakov AV, Porta F, Rohrbach M, Scholl-Bürgi S, Spécola N, Stojiljković M, Shen N, Santana-da Silva LC, Skouma A, van Spronsen F, Stoppioni V, Thöny B, Trefz FK, Vockley J, Yu Y, Zschocke J, Hoffmann GF, Garbade SF, Blau N. The Genetic Landscape and Epidemiology of Phenylketonuria. Am J Hum Genet 2020; 107:234-250. [PMID: 32668217 PMCID: PMC7413859 DOI: 10.1016/j.ajhg.2020.06.006] [Citation(s) in RCA: 121] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 06/05/2020] [Indexed: 11/22/2022] Open
Abstract
Phenylketonuria (PKU), caused by variants in the phenylalanine hydroxylase (PAH) gene, is the most common autosomal-recessive Mendelian phenotype of amino acid metabolism. We estimated that globally 0.45 million individuals have PKU, with global prevalence 1:23,930 live births (range 1:4,500 [Italy]-1:125,000 [Japan]). Comparing genotypes and metabolic phenotypes from 16,092 affected subjects revealed differences in disease severity in 51 countries from 17 world regions, with the global phenotype distribution of 62% classic PKU, 22% mild PKU, and 16% mild hyperphenylalaninemia. A gradient in genotype and phenotype distribution exists across Europe, from classic PKU in the east to mild PKU in the southwest and mild hyperphenylalaninemia in the south. The c.1241A>G (p.Tyr414Cys)-associated genotype can be traced from Northern to Western Europe, from Sweden via Norway, to Denmark, to the Netherlands. The frequency of classic PKU increases from Europe (56%) via Middle East (71%) to Australia (80%). Of 758 PAH variants, c.1222C>T (p.Arg408Trp) (22.2%), c.1066-11G>A (IVS10-11G>A) (6.4%), and c.782G>A (p.Arg261Gln) (5.5%) were most common and responsible for two prevalent genotypes: p.[Arg408Trp];[Arg408Trp] (11.4%) and c.[1066-11G>A];[1066-11G>A] (2.6%). Most genotypes (73%) were compound heterozygous, 27% were homozygous, and 55% of 3,659 different genotypes occurred in only a single individual. PAH variants were scored using an allelic phenotype value and correlated with pre-treatment blood phenylalanine concentrations (n = 6,115) and tetrahydrobiopterin loading test results (n = 4,381), enabling prediction of both a genotype-based phenotype (88%) and tetrahydrobiopterin responsiveness (83%). This study shows that large genotype databases enable accurate phenotype prediction, allowing appropriate targeting of therapies to optimize clinical outcome.
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Affiliation(s)
- Alicia Hillert
- Division of Child Neurology and Metabolic Medicine, Centre for Child and Adolescent Medicine, Clinic I, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Yair Anikster
- Metabolic Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Aviv University, 52621 Tel-Aviv, Israel
| | - Amaya Belanger-Quintana
- Unidad de Enfermedades Metabolicas, Servicio de Pediatria, Hospital Ramon y Cajal, 28034 Madrid, Spain
| | - Alberto Burlina
- Division of Inherited Metabolic Diseases, Department of Woman's and Child's Health, University Hospital, 35129 Padua, Italy
| | - Barbara K Burton
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA
| | - Carla Carducci
- Department of Experimental Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Ana E Chiesa
- Fundación de Endocrinología Infantil (FEI), C1425 Buenos Aires, Argentina
| | - John Christodoulou
- Murdoch Children's Research Institute and Department of Pediatrics, University of Melbourne, Melbourne, VIC 3052, Australia
| | - Maja Đorđević
- Institute of Mother and Child Healthcare "Dr. Vukan Čupić," 11000 Belgrade, Serbia
| | - Lourdes R Desviat
- Centro de Diagnóstico de Enfermedades Moleculares, Centro de Biología Molecular CSIC-UAM, Universidad Autónoma de Madrid. CIBERER, IdiPAz, 28049 Madrid, Spain
| | - Aviva Eliyahu
- Metabolic Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Aviv University, 52621 Tel-Aviv, Israel
| | - Roeland A F Evers
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Section of Metabolic Diseases, 9712 CP Groningen, the Netherlands
| | - Lena Fajkusova
- Centre of Molecular Biology and Gene Therapy, University Hospital Brno, 62500 Brno, Czech Republic
| | - François Feillet
- Reference Center for Inherited Metabolic Diseases, University Hospital of Nancy, 54511 Vandoeuvre-lès-Nancy, France
| | - Pedro E Bonfim-Freitas
- Laboratory of Inborn Errors of Metabolism, Institute of Biological Sciences, Federal University of Pará, Belém 66075-110, Brazil
| | - Maria Giżewska
- Department of Pediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology, Pomeranian Medical University, 71-252 Szczecin, Poland
| | | | - Daniela Karall
- Clinic of Pediatrics, Division of Inherited Metabolic Disorders, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Katya Kneller
- Metabolic Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Aviv University, 52621 Tel-Aviv, Israel
| | | | - Vincenzo Leuzzi
- Department of Human Neuroscience, Sapienza University of Rome, 00185 Rome, Italy
| | - Harvey L Levy
- Division of Genetics and Genomics, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | | | - Ania C Muntau
- University Children's Hospital, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany
| | - Fares Namour
- Reference Center for Inherited Metabolic Diseases, University Hospital of Nancy, 54511 Vandoeuvre-lès-Nancy, France
| | - Mariusz Oltarzewski
- Department of Screening and Metabolic Diagnostics, Institute of Mother and Child, 01-211 Warsaw, Poland
| | - Andrea Paras
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA
| | - Belen Perez
- Centro de Diagnóstico de Enfermedades Moleculares, Centro de Biología Molecular CSIC-UAM, Universidad Autónoma de Madrid. CIBERER, IdiPAz, 28049 Madrid, Spain
| | - Emil Polak
- Comenius University, Faculty of Natural Sciences, Department of Molecular Biology, 84215 Bratislava 4, Slovak Republic
| | | | - Francesco Porta
- Department of Pediatrics, AOU Citta' della Salute e della Scienza di Torino, 10126 Torino, Italy
| | - Marianne Rohrbach
- Division of Metabolism, University Children's Hospital, 8032 Zürich, Switzerland
| | - Sabine Scholl-Bürgi
- Clinic of Pediatrics, Division of Inherited Metabolic Disorders, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Norma Spécola
- Unidad de Metabolismo. Hospital de Niños "Sor Ludovica" de La Plata, 1904 Buenos Aires, Argentina
| | - Maja Stojiljković
- Institute of Molecular Genetics and Genetic Engineering, University of Belgrade, 11000 Belgrade, Serbia
| | - Nan Shen
- Department of Infectious Diseases, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 2000025 Shanghai, China
| | - Luiz C Santana-da Silva
- Laboratory of Inborn Errors of Metabolism, Institute of Biological Sciences, Federal University of Pará, Belém 66075-110, Brazil
| | | | - Francjan van Spronsen
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Section of Metabolic Diseases, 9712 CP Groningen, the Netherlands
| | - Vera Stoppioni
- Centro Screening Neonatale Regione Marche, Azienda Ospedaliera Ospedali Riuniti Marche Nord, 61032 Fano, Italy
| | - Beat Thöny
- Division of Metabolism, University Children's Hospital, 8032 Zürich, Switzerland
| | - Friedrich K Trefz
- Division of Child Neurology and Metabolic Medicine, Centre for Child and Adolescent Medicine, Clinic I, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Jerry Vockley
- UPMC, Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Youngguo Yu
- Department of Pediatric Endocrinology/Genetics, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Institute for Pediatric Research, 2000025 Shanghai, China
| | - Johannes Zschocke
- Institute of Human Genetics, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Georg F Hoffmann
- Division of Child Neurology and Metabolic Medicine, Centre for Child and Adolescent Medicine, Clinic I, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Sven F Garbade
- Division of Child Neurology and Metabolic Medicine, Centre for Child and Adolescent Medicine, Clinic I, University Hospital Heidelberg, 69120 Heidelberg, Germany.
| | - Nenad Blau
- Division of Child Neurology and Metabolic Medicine, Centre for Child and Adolescent Medicine, Clinic I, University Hospital Heidelberg, 69120 Heidelberg, Germany; Division of Metabolism, University Children's Hospital, 8032 Zürich, Switzerland.
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23
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Abstract
BACKGROUND Phenylketonuria is an inherited disease treated with dietary restriction of the amino acid phenylalanine. The diet is initiated in the neonatal period to prevent learning disability; however, it is restrictive and can be difficult to follow. Whether the diet can be relaxed or discontinued during adolescence or should be continued for life remains a controversial issue, which we aim to address in this review. This is an updated version of a previously published review. OBJECTIVES To assess the effects of a low-phenylalanine diet commenced early in life for people with phenylketonuria. To assess the possible effects of relaxation or termination of the diet on intelligence, neuropsychological outcomes and mortality, growth, nutritional status, eating behaviour and quality of life. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearches of relevant journals and abstract books of conference proceedings. Most recent search of the Inborn Errors of Metabolism Trials Register: 30 April 2020. SELECTION CRITERIA All randomised or quasi-randomised controlled trials comparing a low-phenylalanine diet to relaxation or termination of dietary restrictions in people with phenylketonuria. DATA COLLECTION AND ANALYSIS Two authors independently assessed study eligibility and methodological quality, and subsequently extracted the data. MAIN RESULTS We included four studies in this review (251 participants), and found few significant differences between treatment and comparison groups for the outcomes of interest. Blood phenylalanine levels were significantly lower in participants with phenylketonuria following a low-phenylalanine diet compared to those on a less restricted diet, mean difference (MD) at three months -698.67 (95% confidence interval (CI) -869.44 to -527.89). Intelligence quotient was significantly higher in participants who continued the diet than in those who stopped the diet, MD after 12 months 5.00 (95% CI 0.40 to 9.60). However, these results came from a single study. AUTHORS' CONCLUSIONS The results of non-randomised studies have concluded that a low-phenylalanine diet is effective in reducing blood phenylalanine levels and improving intelligence quotient and neuropsychological outcomes. We were unable to find any randomised controlled studies that have assessed the effect of a low-phenylalanine diet versus no diet from diagnosis. In view of evidence from non-randomised studies, such a study would be unethical and it is recommended that low-phenylalanine diet should be commenced at the time of diagnosis. There is uncertainty about the precise level of phenylalanine restriction and when, if ever, the diet should be relaxed. This should be addressed by randomised controlled studies; however, no new studies are expected in this area so we do not plan to update this review.
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Affiliation(s)
- Elisabeth Jameson
- Willink Biochemical Genetics Unit, Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Tracey Remmington
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
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Moat SJ, Schulenburg-Brand D, Lemonde H, Bonham JR, Weykamp CW, Mei JV, Shortland GS, Carling RS. Performance of laboratory tests used to measure blood phenylalanine for the monitoring of patients with phenylketonuria. J Inherit Metab Dis 2020; 43:179-188. [PMID: 31433494 PMCID: PMC7957320 DOI: 10.1002/jimd.12163] [Citation(s) in RCA: 12] [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: 03/07/2019] [Revised: 08/16/2019] [Accepted: 08/19/2019] [Indexed: 01/16/2023]
Abstract
Analysis of blood phenylalanine is central to the monitoring of patients with phenylketonuria (PKU) and age-related phenylalanine target treatment-ranges (0-12 years; 120-360 μmol/L, and >12 years; 120-600 μmol/L) are recommended in order to prevent adverse neurological outcomes. These target treatment-ranges are based upon plasma phenylalanine concentrations. However, patients are routinely monitored using dried bloodspot (DBS) specimens due to the convenience of collection. Significant differences exist between phenylalanine concentrations in plasma and DBS, with phenylalanine concentrations in DBS specimens analyzed by flow-injection analysis tandem mass spectrometry reported to be 18% to 28% lower than paired plasma concentrations analyzed using ion-exchange chromatography. DBS specimens with phenylalanine concentrations of 360 and 600 μmol/L, at the critical upper-target treatment-range thresholds would be plasma equivalents of 461 and 768 μmol/L, respectively, when a reported difference of 28% is taken into account. Furthermore, analytical test imprecision and bias in conjunction with pre-analytical factors such as volume and quality of blood applied to filter paper collection devices to produce DBS specimens affect the final test results. Reporting of inaccurate patient results when comparing DBS results to target treatment-ranges based on plasma concentrations, together with inter-laboratory imprecision could have a significant impact on patient management resulting in inappropriate dietary change and potentially adverse patient outcomes. This review is intended to provide perspective on the issues related to the measurement of phenylalanine in blood specimens and to provide direction for the future needs of PKU patients to ensure reliable monitoring of metabolic control using the target treatment-ranges.
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Affiliation(s)
- Stuart J. Moat
- Department of Medical Biochemistry, Immunology & Toxicology, University Hospital Wales, Cardiff, UK
- School of Medicine, Cardiff University, University Hospital Wales, Cardiff, UK
| | - Danja Schulenburg-Brand
- Department of Medical Biochemistry, Immunology & Toxicology, University Hospital Wales, Cardiff, UK
| | - Hugh Lemonde
- Paediatric Metabolic Medicine, Evelina Children’s Hospital, Guys & St Thomas’ NHSFT, London, UK
| | - James R. Bonham
- Department of Clinical Chemistry, Sheffield Children’s (NHS) FT, Sheffield, UK
| | - Cas W. Weykamp
- MCA Laboratory, Queen Beatrix Hospital, Winterswijk, The Netherlands
| | - Joanne V. Mei
- Newborn Screening and Molecular Biology Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Rachel S. Carling
- Biochemical Sciences, Viapath, Guys & St Thomas’ NHSFT, London, UK
- GKT School of Medical Education, King’s College, London, UK
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Cheung KM, Yang KA, Nakatsuka N, Zhao C, Ye M, Jung ME, Yang H, Weiss PS, Stojanović MN, Andrews AM. Phenylalanine Monitoring via Aptamer-Field-Effect Transistor Sensors. ACS Sens 2019; 4:3308-3317. [PMID: 31631652 PMCID: PMC6957227 DOI: 10.1021/acssensors.9b01963] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [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: 11/29/2022]
Abstract
Determination of the amino acid phenylalanine is important for lifelong disease management in patients with phenylketonuria, a genetic disorder in which phenylalanine accumulates and persists at levels that alter brain development and cause permanent neurological damage and cognitive dysfunction. Recent approaches for treating phenylketonuria focus on injectable medications that efficiently break down phenylalanine but sometimes result in detrimentally low phenylalanine levels. We have identified new DNA aptamers for phenylalanine in two formats, initially as fluorescent sensors and then, incorporated with field-effect transistors (FETs). Aptamer-FET sensors detected phenylalanine over a wide range of concentrations (fM to mM). para-Chlorophenylalanine, which inhibits the enzyme that converts phenylalanine to tyrosine, was used to induce hyperphenylalaninemia during brain development in mice. Aptamer-FET sensors were specific for phenylalanine versus para-chlorophenylalanine and differentiated changes in mouse serum phenylalanine at levels expected in patients. Aptamer-FETs can be used to investigate models of hyperphenylalanemia in the presence of structurally related enzyme inhibitors, as well as naturally occurring amino acids. Nucleic acid-based receptors that discriminate phenylalanine analogs, some that differ by a single substituent, indicate a refined ability to identify aptamers with binding pockets tailored for high affinity and specificity. Aptamers of this type integrated into FETs enable rapid, electronic, label-free phenylalanine sensing.
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Affiliation(s)
- Kevin M. Cheung
- Department of Chemistry and Biochemistry, University of California, Los Angeles, Los Angeles, California 90095, United States
- California NanoSystems Institute, University of California, Los Angeles, Los Angeles, California 90095, United States
| | - Kyung-Ae Yang
- Department of Medicine, Columbia University, New York, New York 10032, United States
| | - Nako Nakatsuka
- Department of Chemistry and Biochemistry, University of California, Los Angeles, Los Angeles, California 90095, United States
- California NanoSystems Institute, University of California, Los Angeles, Los Angeles, California 90095, United States
| | - Chuanzhen Zhao
- Department of Chemistry and Biochemistry, University of California, Los Angeles, Los Angeles, California 90095, United States
- California NanoSystems Institute, University of California, Los Angeles, Los Angeles, California 90095, United States
| | - Mao Ye
- Department of Chemistry and Biochemistry, University of California, Los Angeles, Los Angeles, California 90095, United States
- California NanoSystems Institute, University of California, Los Angeles, Los Angeles, California 90095, United States
| | - Michael E. Jung
- Department of Chemistry and Biochemistry, University of California, Los Angeles, Los Angeles, California 90095, United States
- California NanoSystems Institute, University of California, Los Angeles, Los Angeles, California 90095, United States
| | - Hongyan Yang
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience & Human Behavior, and Hatos Center for Neuropharmacology, University of California, Los Angeles, Los Angeles, California 90095, United States
| | - Paul S. Weiss
- Department of Chemistry and Biochemistry, University of California, Los Angeles, Los Angeles, California 90095, United States
- California NanoSystems Institute, University of California, Los Angeles, Los Angeles, California 90095, United States
- Departments of Bioengineering and Materials Science and Engineering, University of California, Los Angeles, Los Angeles, California 90095, United States
| | - Milan N. Stojanović
- Department of Medicine, Columbia University, New York, New York 10032, United States
- Departments of Biomedical Engineering and Systems Biology, Columbia University, New York, New York 10032, United States
| | - Anne M Andrews
- Department of Chemistry and Biochemistry, University of California, Los Angeles, Los Angeles, California 90095, United States
- California NanoSystems Institute, University of California, Los Angeles, Los Angeles, California 90095, United States
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience & Human Behavior, and Hatos Center for Neuropharmacology, University of California, Los Angeles, Los Angeles, California 90095, United States
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Walkowiak D, Bukowska-Posadzy A, Kałużny Ł, Ołtarzewski M, Staszewski R, Musielak M, Walkowiak J. Therapy compliance in children with phenylketonuria younger than 5 years: A cohort study. ADV CLIN EXP MED 2019; 28:1385-1391. [PMID: 31469949 DOI: 10.17219/acem/104536] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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] [Indexed: 11/24/2022]
Abstract
BACKGROUND Phenylketonuria (PKU) is a metabolic disease. It is manifested by a complete or partial inability to convert phenylalanine (Phe) to tyrosine and leads to increased concentrations of Phe in the blood and in other tissues, including the brain, causing irreversible neurological damage if left untreated. Low-phenylalanine diet is a key component of classical PKU therapy. OBJECTIVES The objective of this study was to assess the effectiveness of classical phenylketonuria therapy and compliance with doctors' recommendations in the first 5 years of life. MATERIAL AND METHODS Data was collected from all diagnosed and treated patients (n = 57) born 1999-2010. Phenylalanine blood levels, the number of visits to a specialist outpatients' center, the number of blood tests, as well as socioeconomic status (SES) and parents' education level have been analyzed, and potential relationships have been assessed. RESULTS In the 1st year of life patients visited their doctors (odds ratio (OR) = 6.8267; 95% confidence interval (95% CI) = 2.827-16.5163; p < 0.0001) and had their blood collected (OR = 2.7875; 95% CI = 1.0467-7.4234; p < 0.0402) significantly more frequently than in the 2nd year. This tendency persisted into subsequent years. Similarly, in infancy they had statistically significantly lower odds of exceeding more than 40% of their Phe levels over therapeutic range than 1 year later (OR = 3.6078; 95% CI = 1.4859-8.7599; p < 0.0046). No PKU child had more than 70% of Phe levels over the therapeutic range in the 1st year of life, whereas 4 years later there were 18 such children. Phe levels were correlated with the number of visits to a specialist (ρ = 0.39) and the number of Phe blood tests with index of dietary control (ρ = -0.33). The effectiveness of therapy and compliance with the doctor's recommendations seem to depend neither on the level of education of the patient's parents nor on their SES. CONCLUSIONS Therapy effectiveness and patients' compliance in PKU is very good in infancy. However, both deteriorate in subsequent years. Moreover, they do not seem to depend on the family background.
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Affiliation(s)
- Dariusz Walkowiak
- Department of Organization and Management in Health Care, Poznan University of Medical Sciences, Poland
| | - Anna Bukowska-Posadzy
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Poland
- Department of Clinical Psychology, Poznan University of Medical Sciences, Poland
| | - Łukasz Kałużny
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Poland
| | - Mariusz Ołtarzewski
- Department of Screening Tests, Institute of Mother and Child, Warszawa, Poland
| | - Rafał Staszewski
- Department of Organization and Management in Health Care, Poznan University of Medical Sciences, Poland
| | - Michał Musielak
- Department of Social Sciences, Poznan University of Medical Sciences, Poland
| | - Jarosław Walkowiak
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Poland
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Azabdaftari A, van der Giet M, Schuchardt M, Hennermann JB, Plöckinger U, Querfeld U. The cardiovascular phenotype of adult patients with phenylketonuria. Orphanet J Rare Dis 2019; 14:213. [PMID: 31492166 PMCID: PMC6731621 DOI: 10.1186/s13023-019-1188-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 08/30/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Patients with Phenylketonuria (PKU) are exposed to multiple cardiovascular risk factors, but the clinical significance of these abnormalities is yet unknown. The purpose of this study was to characterize the cardiovascular phenotype in adult patients with PKU by clinical and dietary data, measurements of biochemical markers, and non-invasive examination of vascular functions. RESULTS Twenty-three adult patients with PKU (age: 18-47 y; 30.8 ± 8.4 y) and 28 healthy controls (age: 18-47 y; 30.1 ± 9.1 y) were included in this study. PKU patients had significantly higher systolic and diastolic blood pressure, increased resting heart rate and a higher body mass index. Total cholesterol and non-HDL cholesterol levels were significantly increased in PKU patients, whereas plasma levels of HDL cholesterol and its subfraction HDL2 (but not HDL3) were significantly decreased. The inflammatory markers C-reactive protein and serum amyloid A protein and the serum oxidative stress marker malondialdehyde were significantly higher in patients with PKU. Venous occlusion plethysmography showed marked reduction in post-ischemic blood flow and the carotid to femoral pulse wave velocity was significantly increased demonstrating endothelial dysfunction and increased vascular stiffness. CONCLUSIONS This study shows that the cardiovascular phenotype of adult PKU patients is characterized by an accumulation of traditional cardiovascular risk factors, high levels of inflammatory and oxidative stress markers, endothelial dysfunction and vascular stiffness. These data indicate the need for early cardiovascular risk reduction in patients with PKU.
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Affiliation(s)
- Aline Azabdaftari
- Department of Pediatrics, Division of Gastroenterology, Nephrology and Metabolic Diseases, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augstenburger Platz 1, 13353, Berlin, Germany
| | - Markus van der Giet
- Department of Nephrology, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Mirjam Schuchardt
- Department of Nephrology, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Julia B Hennermann
- Villa Metabolica, Department of Pediatric and Adolescent Medicine, University Medical Center Mainz, Langenbeckstr, 1, 55131, Mainz, Germany
| | - Ursula Plöckinger
- Interdisciplinary Center of Metabolism: Endocrinology, Diabetes and Metabolism, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Uwe Querfeld
- Department of Pediatrics, Division of Gastroenterology, Nephrology and Metabolic Diseases, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augstenburger Platz 1, 13353, Berlin, Germany.
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Hausmann O, Daha M, Longo N, Knol E, Müller I, Northrup H, Brockow K. Pegvaliase: Immunological profile and recommendations for the clinical management of hypersensitivity reactions in patients with phenylketonuria treated with this enzyme substitution therapy. Mol Genet Metab 2019; 128:84-91. [PMID: 31375398 DOI: 10.1016/j.ymgme.2019.05.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/13/2019] [Accepted: 05/13/2019] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To provide recommendations for managing hypersensitivity adverse events (HAEs) to an injectable enzyme substitution therapy (pegvaliase, a PEGylated phenylalanine ammonia lyase enzyme) in adult patients with phenylketonuria (PKU). METHODS Eight European academic immunology experts with a broad range of experience in hypersensitivity, anaphylaxis, and/or drug reactions, and two geneticists from the USA with pegvaliase experience convened for two advisory board meetings. Efficacy, safety, and immunological profile of pegvaliase were discussed with the objective of developing recommendations for the clinical management of HAEs associated with pegvaliase treatment. RESULTS Based on available immunogenicity data, it was concluded that pegvaliase induces a Type III hypersensitivity reaction, causing HAEs with peak event rates during induction/titration and a decline over time during maintenance therapy. The decline in HAEs with longer duration of therapy was considered to likely be driven by anti-drug antibody affinity maturation, reduced immune complex formation, and decreased complement activation over time. Immunology and PKU experts unanimously supported that the use of an induction, titration, and maintenance dosing regimen and implementation of several risk mitigation strategies contributed to the improvement of tolerability over time. Key risk mitigation strategies utilized in the Phase 3 clinical trials such as premedication with H1-receptor antagonists, allowance for a longer titration period after an HAE, patient education, and requirement to carry auto-injectable adrenaline (epinephrine) should be continued in clinical practice. A tool for administration of auto-injectable adrenaline in patients using pegvaliase was suggested. It was added that after the occurrence of a severe HAE a temporary dose reduction is more likely to improve tolerability than treatment interruption. CONCLUSIONS Overall, it was agreed that pegvaliase has a generally tolerable safety profile in adults with PKU. Importantly, the risk mitigation strategies utilized in the clinical trials were considered to support the continued use of key strategies for management in the commercial setting, such as a slow induction/titration dosing paradigm and premedication with H1-receptor antagonists. However, physicians and patients need to be aware of the risk of HAEs associated with pegvaliase; presence of a trained observer during early treatment may be beneficial in certain circumstances, and a requirement to carry auto-injectable adrenaline is recommended. Because pegvaliase offers the possibility to normalize diet, while maintaining blood phenylalanine within the recommended therapeutic range, safe use of this medication in the clinical setting is important. Ongoing monitoring of long-term clinical safety of patients on pegvaliase treatment in the commercial setting was recommended.
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Affiliation(s)
- Oliver Hausmann
- Adverse Drug Reactions, Analysis & Consulting (ADR-AC) GmbH, Bern, and Research Affiliate, Department of Rheumatology, Immunology and Allergology Inselspital, University of Bern, Switzerland
| | - Mohamed Daha
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
| | - Nicola Longo
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Edward Knol
- Department of Immunology and Dermatology, Department of Allergology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ingo Müller
- Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hope Northrup
- Department of Pediatrics, The McGovern Medical School, Houston, TX, USA
| | - Knut Brockow
- Department of Dermatology and Allergy, School of Medicine Technical University of Munich, Munich, Germany.
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Green B, Rahman Y, Firman S, Adam S, Jenkinson F, Nicol C, Adams S, Dawson C, Robertson L, Dunlop C, Cozens A, Hubbard G, Stratton R. Improved Eating Behaviour and Nutrient Intake in Noncompliant Patients with Phenylketonuria after Reintroducing a Protein Substitute: Observations from a Multicentre Study. Nutrients 2019; 11:nu11092035. [PMID: 31480383 PMCID: PMC6770397 DOI: 10.3390/nu11092035] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 08/21/2019] [Accepted: 08/28/2019] [Indexed: 11/16/2022] Open
Abstract
Noncompliance is widespread in adults with PKU and is associated with adverse metabolic, nutritional and cognitive abnormalities. Returning to the PKU diet is important for this at-risk population, yet for many this is challenging to achieve. Strategies that ease the return to the PKU diet, while offering nutritional and cognitive advantages, are needed. Twelve PKU adults (33.7 ± 2.6 years), who had been noncompliant for 4.5 years (range: 1 to 11 years), took 33 g of a low-volume, nutrient-enriched, protein substitute daily for 28 days. Outcomes of eating behaviour, nutrient intake and mood were assessed at entry (baseline, days 1-3) and after the intervention period (days 29-31). At baseline, intakes of natural protein and estimated phenylalanine were high (66.4 g and 3318.5 mg, respectively) and intakes of calcium, magnesium, iron, zinc, iodine and vitamin D were below country-specific recommendations. With use of the experimental protein substitute, natural protein and estimated phenylalanine intake declined (p = 0.043 for both). Fat and saturated fat intakes also decreased (p = 0.019 and p = 0.041, respectively), while energy and carbohydrate intake remained unchanged. Micronutrient intake increased (p ≤ 0.05 for all aforementioned) to levels well within reference nutrient intake recommendations. Blood vitamin B12 and vitamin D increased by 19.8% and 10.4%, respectively. Reductions in anxiety and confusion were also observed during the course of the study yet should be handled as preliminary data. This study demonstrates that reintroducing a low-volume, nutrient-enriched protein substitute delivers favourable nutritional and possible mood benefits in noncompliant PKU patients, yet longer-term studies are needed to further confirm this. This preliminary knowledge should be used in the design of new strategies to better facilitate patients' return to the PKU diet, with the approach described here as a foundation.
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Affiliation(s)
- Benjamin Green
- Medical Affairs, Nutricia Advanced Medical Nutrition, Wiltshire, BA14 0XQ, UK.
| | - Yusof Rahman
- Guy's and St Thomas' Hospital, London, SE1 9RT, UK
| | - Sarah Firman
- Guy's and St Thomas' Hospital, London, SE1 9RT, UK
| | - Sarah Adam
- Royal Hospital for Children, Glasgow, G51 4TF, UK
| | | | - Claire Nicol
- Royal Victoria Infirmary, Newcastle, NE1 4LP, UK
| | - Sandra Adams
- Royal Victoria Infirmary, Newcastle, NE1 4LP, UK
| | | | | | - Carolyn Dunlop
- Royal Hospital for Sick Children, Edinburgh, EH9 1LF, UK
| | - Alison Cozens
- Royal Hospital for Sick Children, Edinburgh, EH9 1LF, UK
| | - Gary Hubbard
- Medical Affairs, Nutricia Advanced Medical Nutrition, Wiltshire, BA14 0XQ, UK
| | - Rebecca Stratton
- Medical Affairs, Nutricia Advanced Medical Nutrition, Wiltshire, BA14 0XQ, UK
- Faculty of Medicine, University of Southampton, Southampton, SO14 0DA, UK
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30
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van Vliet K, Rodenburg IL, van Ginkel WG, Lubout CMA, Wolffenbuttel BHR, van der Klauw MM, Heiner-Fokkema MR, van Spronsen FJ. Biomarkers of Micronutrients in Regular Follow-Up for Tyrosinemia Type 1 and Phenylketonuria Patients. Nutrients 2019; 11:E2011. [PMID: 31461828 PMCID: PMC6769775 DOI: 10.3390/nu11092011] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 08/16/2019] [Accepted: 08/21/2019] [Indexed: 12/26/2022] Open
Abstract
Phenylketonuria (PKU) is treated with dietary restrictions and sometimes tetrahydrobiopterin (BH4). PKU patients are at risk for developing micronutrient deficiencies, such as vitamin B12 and folic acid, likely due to their diet. Tyrosinemia type 1 (TT1) is similar to PKU in both pathogenesis and treatment. TT1 patients follow a similar diet, but nutritional deficiencies have not been investigated yet. In this retrospective study, biomarkers of micronutrients in TT1 and PKU patients were investigated and outcomes were correlated to dietary intake and anthropometric measurements from regular follow-up measurements from patients attending the outpatient clinic. Data was analyzed using Kruskal-Wallis, Fisher's exact and Spearman correlation tests. Furthermore, descriptive data were used. Overall, similar results for TT1 and PKU patients (with and without BH4) were observed. In all groups high vitamin B12 concentrations were seen rather than B12 deficiencies. Furthermore, all groups showed biochemical evidence of vitamin D deficiency. This study shows that micronutrients in TT1 and PKU patients are similar and often within the normal ranges and that vitamin D concentrations could be optimized.
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Affiliation(s)
- Kimber van Vliet
- Division of Metabolic Diseases, Groningen, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Iris L Rodenburg
- Division of Metabolic Diseases, Groningen, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Willem G van Ginkel
- Division of Metabolic Diseases, Groningen, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Charlotte M A Lubout
- Division of Metabolic Diseases, Groningen, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Bruce H R Wolffenbuttel
- Department of Endocrinology, Groningen, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Melanie M van der Klauw
- Department of Endocrinology, Groningen, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - M Rebecca Heiner-Fokkema
- Laboratory of Metabolic Diseases, Groningen, Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Francjan J van Spronsen
- Division of Metabolic Diseases, Groningen, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands.
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31
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Eshraghi P, Noroozi Asl S, Bagheri S, Chalak V. Response to sapropterin hydrochloride (Kuvan®) in children with phenylketonuria (PKU): a clinical trial. J Pediatr Endocrinol Metab 2019; 32:885-888. [PMID: 31237861 DOI: 10.1515/jpem-2018-0503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 04/23/2019] [Indexed: 01/29/2023]
Abstract
Background Phenylketonuria (PKU) is one of the most common types of inborn error of metabolism. The mainstay of therapy for PKU has been dietary phenylalanine (Phe) restriction. Sapropterin dihydrochloride has been shown to be effective in reducing Phe levels in PKU patients. Methods This study was a clinical trial performed in the pediatric endocrine clinic of Imam Reza Hospital, Mashhad, Iran. Results All children between 1 and 10 years of age with a diagnosis of PKU whose serum Phe levels were between 120 and 360 μmol/L, in Khorasan Razavi province in the north-east of Iran, were enrolled. Twenty-four patients were enrolled in the study. Intervention: A free diet for 72 h was allowed and then a 20-mg/kg/day dose of Kuvan® was administered. More than 30% reduction in blood Phe levels was described as responsive. Eight patients responded to the loading test and were eligible for the second stage of the study. In this stage, Phe powder in combination with Kuvan was provided. Patients' serum Phe was measured weekly for 3 months. All eight patients showed Phe tolerance in 3 months, and their serum Phe levels remained within the range. Conclusions Treatment with Kuvan can help reduce blood Phe levels in our pediatric PKU population and allows patients to follow a more liberal diet.
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Affiliation(s)
- Peyman Eshraghi
- Department of Pediatric Endocrinology and Metabolism, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Samaneh Noroozi Asl
- Department of Pediatric Endocrinology and Metabolism, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sepideh Bagheri
- Assistant Professor of Pediatrics, Department of Pediatrics, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran, Phone: +989155255451
| | - Vajiheh Chalak
- Department of Pediatrics, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Pilotto A, Blau N, Leks E, Schulte C, Deuschl C, Zipser C, Piel D, Freisinger P, Gramer G, Kölker S, Haas D, Burgard P, Nawroth P, Georg H, Scheffler K, Berg D, Trefz F. Cerebrospinal fluid biogenic amines depletion and brain atrophy in adult patients with phenylketonuria. J Inherit Metab Dis 2019; 42:398-406. [PMID: 30706953 DOI: 10.1002/jimd.12049] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [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: 11/04/2018] [Accepted: 12/31/2018] [Indexed: 01/29/2023]
Abstract
Biogenic amines synthesis in phenylketonuria (PKU) patients with high phenylalanine (Phe) concentration is thought to be impaired due to inhibition of tyrosine and tryptophan hydroxylases and competition with amino acids at the blood-brain barrier. Dopamine and serotonin deficits might explain brain damage and progressive neuropsychiatric impairment in adult PKU patients. Ten early treated adult PKU patients (mean age 38.2 years) and 15 age-matched controls entered the study. Plasma and cerebrospinal fluid (CSF) Phe, 5-hydroxyindoleacetic acid (5-HIAA), 5-hydroxytryptophan (5-HTP), 3,4-dihydroxy-l-phenylalanine (l-DOPA) and homovanillic acid (HVA) were analyzed. Voxel-based morphometry statistical nonparametric mapping was used to test the age-corrected correlation between gray matter atrophy and CSF biogenic amines levels. 5-HIAA and 5-HTP were significantly reduced in PKU patients compared to controls. Significant negative correlations were found between CSF 5-HIAA, HVA, and 5-HTP and Phe levels. A decrease in 5-HIAA and 5-HTP concentrations correlated with precuneus and frontal atrophy, respectively. Lower HVA levels correlated with occipital atrophy. Biogenic amines deficits correlate with specific brain atrophy patterns in adult PKU patients, in line with serotonin and dopamine projections. These findings may support a more rigorous Phe control in adult PKU to prevent neurotransmitter depletion and accelerated brain damage due to aging.
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Affiliation(s)
- Andrea Pilotto
- Department of Neurodegeneration, Hertie Institute of Clinical Brain Research, University of Tübingen, Tübingen, Germany
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Parkinson's Disease Rehabilitation Centre, FERB ONLUS S. Isidoro Hospital, Trescore Balneario, Italy
| | - Nenad Blau
- Department of Pediatrics, Division for Neuropediatrics and Metabolic Medicine, University of Heidelberg, Heidelberg, Germany
| | - Edytha Leks
- Department of Biomedical Magnetic Resonance, University of Tübingen, Tübingen, Germany
| | - Claudia Schulte
- Department of Neurodegeneration, Hertie Institute of Clinical Brain Research, University of Tübingen, Tübingen, Germany
- German Center for Neurodegenerative Diseases, Department of Neurodegeneration, Tübingen, Germany
| | - Christian Deuschl
- Department of Neurodegeneration, Hertie Institute of Clinical Brain Research, University of Tübingen, Tübingen, Germany
- German Center for Neurodegenerative Diseases, Department of Neurodegeneration, Tübingen, Germany
| | - Carl Zipser
- Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - David Piel
- Department of Endocrinology, Internal Medicine I, University of Heidelberg, Heidelberg, Germany
| | | | - Gwendolyn Gramer
- Department of Pediatrics, Division for Neuropediatrics and Metabolic Medicine, University of Heidelberg, Heidelberg, Germany
| | - Stefan Kölker
- Department of Pediatrics, Division for Neuropediatrics and Metabolic Medicine, University of Heidelberg, Heidelberg, Germany
| | - Dorothea Haas
- Department of Pediatrics, Division for Neuropediatrics and Metabolic Medicine, University of Heidelberg, Heidelberg, Germany
| | - Peter Burgard
- Department of Pediatrics, Division for Neuropediatrics and Metabolic Medicine, University of Heidelberg, Heidelberg, Germany
| | - Peter Nawroth
- Department of Endocrinology, Internal Medicine I, University of Heidelberg, Heidelberg, Germany
| | - Hoffmann Georg
- Department of Pediatrics, Division for Neuropediatrics and Metabolic Medicine, University of Heidelberg, Heidelberg, Germany
| | - Klaus Scheffler
- Department of Biomedical Magnetic Resonance, University of Tübingen, Tübingen, Germany
- Magnetic Resonance Centre, Max-Planck-Institute for Biological Cybernetics, Tübingen, Germany
| | - Daniela Berg
- Department of Neurodegeneration, Hertie Institute of Clinical Brain Research, University of Tübingen, Tübingen, Germany
- German Center for Neurodegenerative Diseases, Department of Neurodegeneration, Tübingen, Germany
- Department of Neurology, University-Hospital-Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
| | - Friedrich Trefz
- Department of Pediatrics, Division for Neuropediatrics and Metabolic Medicine, University of Heidelberg, Heidelberg, Germany
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Qu J, Yang T, Wang E, Li M, Chen C, Ma L, Zhou Y, Cui Y. Efficacy and safety of sapropterin dihydrochloride in patients with phenylketonuria: A meta-analysis of randomized controlled trials. Br J Clin Pharmacol 2019; 85:893-899. [PMID: 30720885 PMCID: PMC6475685 DOI: 10.1111/bcp.13886] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/08/2019] [Accepted: 01/19/2019] [Indexed: 12/22/2022] Open
Abstract
AIMS The aim of the present meta-analysis was to evaluate the efficacy and safety of sapropterin dihydrochloride in phenylketonuria (PKU) patients. METHODS The following databases were searched for randomized controlled trials (RCT) regarding PKU patients treated with sapropterin dihydrochloride: PubMed, Embase, Cochrane Library and clinicaltrials. Two authors independently selected studies, assessed the risk of bias and extracted data. The meta-analysis was performed in RevMan 5.3 provided by the Cochrane Collaboration. RESULTS Four studies met the inclusion criteria. In PKU patients with low blood phenylalanine (Phe) concentration, no significant difference was indicated for the decrease of Phe level (weighted mean difference (WMD) = -7.75 μmol L-1 ; 95% confidence intervals (CI): -82.63 to 67.13, P = 0.84, I2 = 0%), however, the dietary Phe tolerance was significantly improved in the sapropterin group (WMD = 19.89 mg kg-1 d-1 ; 95% CI: 10.26 to 29.52, P < 0.0001, I2 = 0%). In PKU patients with high blood Phe level, sapropterin showed a significant lowering in blood Phe concentration (WMD = -225.31 μmol L-1 ; 95% CI: -312.28 to -138.34, P < 0.00001, I2 = 0%). There was no significant difference for adverse events. CONCLUSIONS Sapropterin could bring benefit for PKU patients with high or low Phe level, due to Phe reduction in a short time or dietary Phe tolerance improvement respectively. Sapropterin has an acceptable safety profile.
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Affiliation(s)
- Jinghan Qu
- Department of PharmacyPeking University First Hospital8 Xishiku Street, Xicheng DistrictBeijing100034China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical SciencesPeking University Health Science Center38 Xueyuan Rd, Haidian District100191China
| | - Ting Yang
- Department of PharmacyPeking University First Hospital8 Xishiku Street, Xicheng DistrictBeijing100034China
| | - Ente Wang
- Department of PharmacyPeking University First Hospital8 Xishiku Street, Xicheng DistrictBeijing100034China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical SciencesPeking University Health Science Center38 Xueyuan Rd, Haidian District100191China
| | - Min Li
- Department of PharmacyPeking University First Hospital8 Xishiku Street, Xicheng DistrictBeijing100034China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical SciencesPeking University Health Science Center38 Xueyuan Rd, Haidian District100191China
| | - Chaoyang Chen
- Department of PharmacyPeking University First Hospital8 Xishiku Street, Xicheng DistrictBeijing100034China
| | - Lingyun Ma
- Department of PharmacyPeking University First Hospital8 Xishiku Street, Xicheng DistrictBeijing100034China
| | - Ying Zhou
- Department of PharmacyPeking University First Hospital8 Xishiku Street, Xicheng DistrictBeijing100034China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical SciencesPeking University Health Science Center38 Xueyuan Rd, Haidian District100191China
| | - Yimin Cui
- Department of PharmacyPeking University First Hospital8 Xishiku Street, Xicheng DistrictBeijing100034China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical SciencesPeking University Health Science Center38 Xueyuan Rd, Haidian District100191China
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Gupta S, Lau K, Harding CO, Shepherd G, Boyer R, Atkinson JP, Knight V, Olbertz J, Larimore K, Gu Z, Li M, Rosen O, Zoog SJ, Weng HH, Schweighardt B. Association of immune response with efficacy and safety outcomes in adults with phenylketonuria administered pegvaliase in phase 3 clinical trials. EBioMedicine 2018; 37:366-373. [PMID: 30366815 PMCID: PMC6286649 DOI: 10.1016/j.ebiom.2018.10.038] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 10/12/2018] [Accepted: 10/12/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND This study assessed the immunogenicity of pegvaliase (recombinant Anabaena variabilis phenylalanine [Phe] ammonia lyase [PAL] conjugated with polyethylene glycol [PEG]) treatment in adults with phenylketonuria (PKU) and its impact on safety and efficacy. METHODS Immunogenicity was assessed during induction, upward titration, and maintenance dosing regimens in adults with PKU (n = 261). Total antidrug antibodies (ADA), neutralizing antibodies, immunoglobulin (Ig) M and IgG antibodies against PAL and PEG, IgG and IgM circulating immune complex (CIC) levels, complement components 3 and 4 (C3/C4), plasma Phe, and safety were assessed at baseline and throughout the study. Pegvaliase-specific IgE levels were measured in patients after hypersensitivity adverse events (HAE). FINDINGS All patients developed ADA against PAL, peaking by 6 months and then stabilizing. Most developed transient antibody responses against PEG, peaking by 3 months, then returning to baseline by 9 months. Binding of ADA to pegvaliase led to CIC formation and complement activation, which were highest during early treatment. Blood Phe decreased over time as CIC levels and complement activation declined and pegvaliase dosage increased. HAEs were most frequent during early treatment and declined over time. No patient with acute systemic hypersensitivity events tested positive for pegvaliase-specific IgE near the time of the event. Laboratory evidence was consistent with immune complex-mediated type III hypersensitivity. No evidence of pegvaliase-associated IC-mediated end organ damage was noted. INTERPRETATION Despite a universal ADA response post-pegvaliase administration, adult patients with PKU achieved substantial and sustained blood Phe reductions with a manageable safety profile. FUND: BioMarin Pharmaceutical Inc.
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Affiliation(s)
- Soumi Gupta
- BioMarin Pharmaceutical Inc., 105 Digital Dr, Novato, CA 94949, United States.
| | - Kelly Lau
- BioMarin Pharmaceutical Inc., 105 Digital Dr, Novato, CA 94949, United States
| | - Cary O Harding
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, United States
| | - Gillian Shepherd
- Weill Medical College of Cornell University, 47 East 91st St, New York, NY 10128, United States
| | - Ryan Boyer
- BioMarin Pharmaceutical Inc., 105 Digital Dr, Novato, CA 94949, United States
| | - John P Atkinson
- Washington University School of Medicine, Campus Box 8045, 660 S. Euclid Ave, St. Louis, MO 63110, United States
| | - Vijaya Knight
- National Jewish Health Advanced Diagnostic Laboratories, 1400 Jackson St, Denver, CO 80206, United States
| | - Joy Olbertz
- BioMarin Pharmaceutical Inc., 105 Digital Dr, Novato, CA 94949, United States
| | - Kevin Larimore
- BioMarin Pharmaceutical Inc., 105 Digital Dr, Novato, CA 94949, United States
| | - Zhonghu Gu
- BioMarin Pharmaceutical Inc., 105 Digital Dr, Novato, CA 94949, United States
| | - Mingjin Li
- BioMarin Pharmaceutical Inc., 105 Digital Dr, Novato, CA 94949, United States
| | - Orli Rosen
- BioMarin Pharmaceutical Inc., 105 Digital Dr, Novato, CA 94949, United States
| | - Stephen J Zoog
- BioMarin Pharmaceutical Inc., 105 Digital Dr, Novato, CA 94949, United States
| | - Haoling H Weng
- BioMarin Pharmaceutical Inc., 105 Digital Dr, Novato, CA 94949, United States
| | - Becky Schweighardt
- BioMarin Pharmaceutical Inc., 105 Digital Dr, Novato, CA 94949, United States
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Burton BK, Jones KB, Cederbaum S, Rohr F, Waisbren S, Irwin DE, Kim G, Lilienstein J, Alvarez I, Jurecki E, Levy H. Prevalence of comorbid conditions among adult patients diagnosed with phenylketonuria. Mol Genet Metab 2018; 125:228-234. [PMID: 30266197 DOI: 10.1016/j.ymgme.2018.09.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [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: 07/12/2018] [Revised: 08/23/2018] [Accepted: 09/10/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Phenylalanine hydroxylase (PAH) deficiency, otherwise known as phenylketonuria (PKU), is an inborn error of metabolism that requires treatment to be initiated in the newborn period and continued throughout life. Due to the challenges of treatment adherence and the resulting cumulative effects of high and labile blood phenylalanine, PKU exerts a significant burden of disease. Retrospective studies using large databases allow for unique perspectives on comorbidities associated with rare diseases. An evaluation of comorbidities across various organ systems is warranted to understand the disease burden in adult patients. OBJECTIVES The aim of this insurance claim-based observational study was to assess the prevalence of comorbid conditions across various organ systems (e.g. dermatological, renal, respiratory, gastrointestinal, hematological, and others) among adult PKU patients compared with matched controls from the general population. METHODS This retrospective, case-controlled study selected patients from United States insurance claims databases from 1998 to 2014 using International Classification of Diseases, Ninth Revision (ICD-9) codes for diagnosis of PKU. The date of first diagnosis during the study period was index date and this was not necessarily the first time the patient was diagnosed with PKU. Cases were matched with a 1:5 ratio with general population (non-PKU controls) on age, sex, race, geographic location, duration of time in the database and insurance type. Prevalence and prevalence ratio (PR) calculations for comorbidities across various organ systems among adults (≥20 years old) with PKU were compared with the general population (non-PKU controls). The conditions were selected based on complications associated with PKU and feedback from clinicians treating PKU patients. RESULTS A total of 3691 PKU patients and 18,455 matched, non-PKU controls were selected, with an average age of 35 years. The mean healthcare costs incurred by the PKU patients during baseline, were approximately 4 times that of the controls ($4141 vs $1283; p < .0001). The prevalence rates of comorbidities across various organ systems during the follow-up period were significantly higher for those with PKU than in the control group. After adjusting for baseline characteristics, the adjusted prevalence ratios (PR) of 15 conditions studied (asthma, alopecia, urticaria, gallbladder disease, rhinitis, esophageal disorders, anemia, overweight, GERD, eczema, renal insufficiency, osteoporosis, gastritis/esophagitis and kidney calculus) were all above PR = 1.24 and significantly higher for the PKU cohort (p ≤ .001). The highest adjusted PR were for renal insufficiency with hypertension (PR [95% CI]: 2.20 [1.60-3.00]; p < .0001) and overweight (PR [95%CI]: 2.06 [1.85-2.30]; p < .0001). CONCLUSIONS The prevalence of selected comorbidities across several organ systems is significantly higher among PKU patients than for general population controls. Regular screening for common co-morbidities may be warranted as part of PKU management.
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Affiliation(s)
- Barbara K Burton
- Ann & Robert Lurie Children's Hospital, 225 E. Chicago Ave., Chicago, IL 60611, United States
| | - Kyle Bradford Jones
- University of Utah School of Medicine, Department of Family and Preventive Medicine, 375 Chipeta Way Ste A., Salt Lake City, UT 84108, United States
| | - Stephen Cederbaum
- University of California, Los Angeles, 635 Charles E Young Dr Los Angeles, CA 90095-7332, United States
| | - Fran Rohr
- Boston Children's Hospital and Harvard Medical School, 1 Autumn St., Rm #526, Boston, MA 02115, United States
| | - Susan Waisbren
- Boston Children's Hospital and Harvard Medical School, 1 Autumn Street, #525, Boston, MA 02115, United States
| | - Debra E Irwin
- Truven Health Analytics, An IBM Watson Health Company, 7700 Old Georgetown Rd, 6th Floor, Bethesda, MD 20814, United States
| | - Gilwan Kim
- Truven Health Analytics, An IBM Watson Health Company, 7700 Old Georgetown Rd, 6th Floor, Bethesda, MD 20814, United States
| | - Joshua Lilienstein
- BioMarin Pharmaceutical Inc., 105 Digital Drive, Novato, CA 94949, United States
| | - Ignacio Alvarez
- BioMarin Pharmaceutical Inc., 105 Digital Drive, Novato, CA 94949, United States
| | - Elaina Jurecki
- BioMarin Pharmaceutical Inc., 105 Digital Drive, Novato, CA 94949, United States.
| | - Harvey Levy
- Boston Children's Hospital and Harvard Medical School, 1 Autumn St., Rm #526, Boston, MA 02115, United States
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Zori R, Thomas JA, Shur N, Rizzo WB, Decker C, Rosen O, Li M, Schweighardt B, Larimore K, Longo N. Induction, titration, and maintenance dosing regimen in a phase 2 study of pegvaliase for control of blood phenylalanine in adults with phenylketonuria. Mol Genet Metab 2018; 125:217-227. [PMID: 30146451 DOI: 10.1016/j.ymgme.2018.06.010] [Citation(s) in RCA: 16] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 05/30/2018] [Accepted: 06/20/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Phenylketonuria (PKU) is caused by a deficiency in phenylalanine hydroxylase enzyme activity that leads to phenylalanine (Phe) accumulation in the blood and brain. Elevated blood Phe levels are associated with complications in adults, including neurological, psychiatric, and cognitive issues. Even with nutrition and pharmacological management, the majority of adults with PKU do not maintain blood Phe levels at or below guideline recommended levels. Pegvaliase, PEGylated recombinant Anabaena variabilis phenylalanine ammonia lyase (PAL), converts Phe to trans-cinnamic acid and ammonia, and is an investigational enzyme substitution therapy to lower blood Phe in adults with PKU. METHODS Pegvaliase was administered using an induction, titration, and maintenance dosing regimen in adults with PKU naïve to pegvaliase treatment. Doses were gradually increased until blood Phe ≤ 600 μmol/L was achieved. The maintenance dose was the dose at which participants achieved and sustained blood Phe ≤ 600 μmol/L for at least 4 weeks without dose modification. Analyses were performed for participants who achieved (Group A, n = 11) and did not achieve (Group B, n = 13) maintenance dose during the first 24 weeks of study treatment. RESULTS Baseline mean blood Phe for Group A and Group B were 1135 μmol/L and 1198 μmol/L, respectively. Mean blood Phe ≤ 600 μmol/L was achieved for Group A by Week 11 (mean blood Phe of 508 ± 483 μmol/L) and for Group B by Week 48 (mean blood Phe of 557 ± 389 μmol/L). The most common adverse events involved hypersensitivity reactions, which were mostly mild to moderate in severity and decreased over time. One participant in Group B had four acute systemic hypersensitivity events of anaphylaxis consistent with clinical National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network criteria; all events were non-IgE mediated and resolved without sequelae, with pegvaliase dosing discontinued after the fourth event. The incidence and titers of anti-drug antibodies were generally lower in Group A compared to Group B. CONCLUSIONS Pegvaliase administered with an induction, titration, and maintenance dosing regimen demonstrated substantial efficacy at reducing blood Phe in both Group A and Group B by Week 48, with a manageable safety profile in most participants. Blood Phe reduction due to pegvaliase appears to be related to dose, treatment duration, and individual immune response; given additional time on treatment and dose titration, later Phe responders (Group B) achieved benefit similar to early Phe responders (Group A), with similar long-term safety profiles.
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Affiliation(s)
- Roberto Zori
- Department of Pediatrics in the College of Medicine, University of Florida, Gainesville, FL, USA.
| | - Janet A Thomas
- Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Natasha Shur
- Pediatrics Genetics Group, Albany Medical Center, Albany, NY, USA
| | - William B Rizzo
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Orli Rosen
- BioMarin Pharmaceutical Inc., Novato, CA, USA
| | - Mingjin Li
- BioMarin Pharmaceutical Inc., Novato, CA, USA
| | | | | | - Nicola Longo
- Division of Medical Genetics, University of Utah, Salt Lake City, UT, USA
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Brantley KD, Douglas TD, Singh RH. One-year follow-up of B vitamin and Iron status in patients with phenylketonuria provided tetrahydrobiopterin (BH4). Orphanet J Rare Dis 2018; 13:192. [PMID: 30373601 PMCID: PMC6206913 DOI: 10.1186/s13023-018-0923-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 10/02/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND People with Phenylketonuria (PKU) who respond to tetrahydrobiopterin (BH4) often decrease dependence on medical food (MF) following increased phenylalanine (phe) tolerance. Responders to BH4 may experience a reduction in certain nutrients if not compensated through intact foods or supplements. This study investigated B6, B12, folate, and iron status based on blood levels and dietary intake in patients with PKU responsive to BH4 over 1 year. METHODS Fifty-eight patients with PKU, ages 4-50 years were recruited and initiated on BH4 therapy. Patients were monitored for BH4 response, and nutritional status was recorded at regular intervals over 12 months. The analysis included 33 patients with known BH4 response status and complete nutritional data. Nutrient intake was determined by National Data System for Research (NDSR) analysis of self reported 3 day diet records and compared to Dietary Reference Intakes (DRIs). Blood biomarkers were analyzed by Quest Diagnostics and compared to laboratory reference ranges. Patient laboratory values were compared to controls from the National Health and Examination Survey (NHANES). Differences in nutrient intakes across time points were examined, stratified by age, using nonparametric methods. Statistical analyses were completed with SAS 9.4, with significance set at α = 0.05. RESULTS Medical food intake declined among pediatric (p < 0.01) and adult (p = 0.06) BH4 responders over 1 year. Among those < 18 years of age, mean percent of calories obtained from MF declined from 21.3 to 4.7%. In adults, percent calories from MF dropped from 19.5 to 4.0%. Though maintaining laboratory and dietary values within reference ranges, responders < 18 years experienced a significant decline in serum B12 (p = 0.01), dietary folate (p = 0.006), and dietary iron (p = 0.004) over the study. CONCLUSION Although mean dietary and laboratory values for B12, B6, folate, and iron in BH4 responders and non-responders were adequate at baseline and 12-month follow-up, responders experienced a significant decline in serum B12 over 1 year, which may be explained by decreased intake of fortified MF. Both response groups had lower serum B12 than NHANES controls at baseline and 12 months. Results indicate a need to monitor B12 concentrations and consider micronutrient supplementation, with special attention to pediatric patients with PKU.
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Affiliation(s)
| | - Teresa D Douglas
- Department of Human Genetics, Metabolic Nutrition Program, Emory University School of Medicine, Atlanta, GA USA
| | - Rani H Singh
- Department of Human Genetics, Metabolic Nutrition Program, Emory University School of Medicine, Atlanta, GA USA
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Bartus A, Palasti F, Juhasz E, Kiss E, Simonova E, Sumanszki C, Reismann P. The influence of blood phenylalanine levels on neurocognitive function in adult PKU patients. Metab Brain Dis 2018; 33:1609-1615. [PMID: 29948654 DOI: 10.1007/s11011-018-0267-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 06/06/2018] [Indexed: 10/14/2022]
Abstract
It is well known that hyperphenylalaninemia caused by phenylketonuria (PKU) negatively influences cognitive performance. Several tests have been used to study these functions. Until now, no universal, optimal tool has been developed for detecting PKU-caused brain dysfunctions. Using computerized neuropsychological tests during daily routine would be helpful for screening subclinical brain deficits in adult PKU patients. In a monocentric, cross-sectional study, adult patients with PKU (n = 46; median age = 29.5 years; female/male ratio = 21/25) were tested with the computerized Cambridge Cognition (CANTAB) test measuring neurocognitive functions. Patients were divided into two groups: The "on diet" group included patients whose blood Phe-level was under 600 μmol/l (n = 20), and the "loose diet" group included patients whose blood Phe-level was above 600 μmol/l (n = 26) at the examination time. The results of the PKU-affected individuals were compared with a healthy control group (n = 31; median age = 25 years; female/male ratio = 11/20). Compared with the control group, PKU patients had significantly worse test results in memory, problem-solving skills, and strategy. However, there were no significant differences in response speed or initial thinking time. There was no correlation between the blood Phe-level, tyrosine (Tyr)-level or Phe/Tyr ratio and the different cognitive test results. There were no significant differences in test results between the two PKU subgroups. Several cognitive functions measured by CANTAB are negatively influenced by hyperphenylalaninemia in adult PKU patients. However, response speed and initial thinking time were not impaired as seriously as other functions. Patients with lower Phe-levels failed to achieve better test results than patients whose Phe-levels were notably elevated.
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Affiliation(s)
- A Bartus
- 2nd Department of Internal Medicine, Semmelweis University, Szentkirályi Street 46, Budapest, H-1088, Hungary
| | - F Palasti
- 2nd Department of Internal Medicine, Semmelweis University, Szentkirályi Street 46, Budapest, H-1088, Hungary
| | - E Juhasz
- 2nd Department of Internal Medicine, Semmelweis University, Szentkirályi Street 46, Budapest, H-1088, Hungary
| | - E Kiss
- 1st Department of Pediatrics, Semmelweis University, Bókay János u. 53-54, Budapest, H-1083, Hungary
| | - E Simonova
- 1st Department of Pediatrics, Semmelweis University, Bókay János u. 53-54, Budapest, H-1083, Hungary
| | - Cs Sumanszki
- 2nd Department of Internal Medicine, Semmelweis University, Szentkirályi Street 46, Budapest, H-1088, Hungary
| | - P Reismann
- 2nd Department of Internal Medicine, Semmelweis University, Szentkirályi Street 46, Budapest, H-1088, Hungary.
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Hofman DL, Champ CL, Lawton CL, Henderson M, Dye L. A systematic review of cognitive functioning in early treated adults with phenylketonuria. Orphanet J Rare Dis 2018; 13:150. [PMID: 30165883 PMCID: PMC6117942 DOI: 10.1186/s13023-018-0893-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [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: 07/30/2018] [Accepted: 08/16/2018] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Even though early dietary management of phenylketonuria (PKU) successfully prevents severe neurological impairments, deficits in cognitive functioning are still observed. These deficits are believed to be the result of elevated levels of phenylalanine throughout life. Research on cognitive functioning in adults with PKU (AwPKU) often focuses on domains shown to be compromised in children with PKU, such as attention and executive functions, whereas other cognitive domains have received less attention. This systematic review aimed to provide an overview of cognitive functioning across domains examined in early treated (ET) AwPKU. METHODS A systematic search was performed in Ovid MEDLINE(R), PsycINFO, Web of Science, Cochrane, Scopus, Embase, ScienceDirect, and PubMed for observational studies on cognitive performance in ET AwPKU. RESULTS Twenty-two peer-reviewed publications, reporting on outcomes from 16 studies were reviewed. Collectively, the results most consistently showed deficits in vigilance, working memory and motor skills. Deficits in other cognitive domains were less consistently observed or were understudied. Furthermore, despite reports of several associations between cognitive performance and phenylalanine (Phe) levels throughout life the relationship remains unclear. Inconsistencies in findings across studies could be explained by the highly heterogeneous nature of study samples, resulting in large inter- and intra-variability in Phe levels, as well as the use of a variety of tests across cognitive domains, which differ in sensitivity. The long-term cognitive outcomes of early and continuous management of PKU remain unclear. CONCLUSIONS To better understand the development of cognitive deficits in ET AwPKU, future research would benefit from 1) (inter)national multicentre-studies; 2) more homogeneous study samples; 3) the inclusion of other nutritional measures that might influence cognitive functioning (e.g. Phe fluctuations, Phe:Tyrosine ratio and micronutrients such as vitamin B12); and 4) careful selection of appropriate cognitive tests.
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Affiliation(s)
| | | | | | - Mick Henderson
- Biochemical Genetics, Specialist Laboratory Medicine, St James’s University Hospital, Block 46, Leeds, LS9 7TF UK
| | - Louise Dye
- School of Psychology, University of Leeds, Leeds, LS2 9JT UK
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40
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Evers RAF, van Wegberg AMJ, van Dam E, de Vries MC, Janssen MCH, van Spronsen FJ. Anthropomorphic measurements and nutritional biomarkers after 5 years of BH 4 treatment in phenylketonuria patients. Mol Genet Metab 2018; 124:238-242. [PMID: 30078395 DOI: 10.1016/j.ymgme.2018.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 06/17/2018] [Accepted: 06/17/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Roeland A F Evers
- University of Groningen, University Medical Center Groningen, Division of Metabolic Diseases, PO box 30.001, 9700 RB Groningen, The Netherlands
| | - Annemiek M J van Wegberg
- University of Groningen, University Medical Center Groningen, Division of Metabolic Diseases, PO box 30.001, 9700 RB Groningen, The Netherlands; Radboud University Medical Center Nijmegen, Department of Gastroenterology and Hepatology-Dietetics, PO box 9101, 6500 HB Nijmegen, The Netherlands
| | - Esther van Dam
- University of Groningen, University Medical Center Groningen, Division of Metabolic Diseases, PO box 30.001, 9700 RB Groningen, The Netherlands
| | - Maaike C de Vries
- Radboud University Medical Center Nijmegen, Department of Pediatrics, PO box 9101, 6500 HB Nijmegen, The Netherlands
| | - Mirian C H Janssen
- Radboud University Medical Center, Department of Internal Medicine, PO box 9101, 6500 HB Nijmegen, The Netherlands
| | - Francjan J van Spronsen
- University of Groningen, University Medical Center Groningen, Division of Metabolic Diseases, PO box 30.001, 9700 RB Groningen, The Netherlands.
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Longo N, Zori R, Wasserstein MP, Vockley J, Burton BK, Decker C, Li M, Lau K, Jiang J, Larimore K, Thomas JA. Long-term safety and efficacy of pegvaliase for the treatment of phenylketonuria in adults: combined phase 2 outcomes through PAL-003 extension study. Orphanet J Rare Dis 2018; 13:108. [PMID: 29973227 PMCID: PMC6031112 DOI: 10.1186/s13023-018-0858-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 06/27/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Deficiency of phenylalanine hydroxylase causes phenylketonuria (PKU) with elevated phenylalanine (Phe) levels and associated neuropsychiatric and neurocognitive symptoms. Pegvaliase (PEGylated phenylalanine ammonia lyase) is an investigational agent to lower plasma Phe in adults with PKU. This study aimed to characterize the long-term efficacy, safety, and immunogenicity of pegvaliase in adults with PKU. METHODS PAL-003 is an ongoing, open-label, long-term extension study of the pegvaliase dose-finding parent phase 2 studies. Participants continued the dose of pegvaliase from one of three parent studies, with dose adjustments to achieve a plasma Phe concentration between 60 and 600 μmol/L. RESULTS Mean (standard deviation [SD]) plasma Phe at treatment-naïve baseline for 80 participants in the parent studies was 1302.4 (351.5) μmol/L. In the 68 participants who entered the extension study, plasma Phe decreased 58.9 (39)% from baseline, to 541.6 (515.5) μmol/L at Week 48 of treatment. Plasma Phe concentrations ≤120 μmol/L, ≤360 μmol/L, and ≤ 600 μmol/L were achieved by 78.7, 80.0, and 82.5% of participants, respectively. Mean (SD) protein intake at baseline was 69.4 (40.4) g/day (similar to the recommended intake for the unaffected population) and remained stable throughout the study. All participants experienced adverse events (AEs), which were limited to mild or moderate severity in most (88.8%); the most common AEs were injection-site reaction (72.5%), injection-site erythema (67.5%), headache (67.5%), and arthralgia (65.0%). The AE rate decreased from 58.3 events per person-year in the parent studies to 18.6 events per person-year in the extension study. CONCLUSIONS Pegvaliase treatment in adults with PKU produced meaningful and persistent reductions in mean plasma Phe concentration with a manageable safety profile for most subjects that continued with long-term treatment. TRIAL REGISTRATION ClinicalTrials.gov , NCT00924703. Registered June 18, 2009, https://clinicaltrials.gov/ct2/show/NCT00924703.
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Affiliation(s)
- Nicola Longo
- Department of Pediatrics, Division of Medical Genetics, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108 USA
| | - Roberto Zori
- Division of Genetics and Metabolism, University of Florida, PO Box 100296 UFHSC, Gainesville, FL 32610 USA
| | - Melissa P. Wasserstein
- Department of Pediatrics, The Children’s Hospital at Montefiore, 3415 Bainbridge Ave, Bronx, NY 10467 USA
| | - Jerry Vockley
- Department of Pediatrics, Division of Medical Genetics, University of Pittsburgh and Children’s Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224 USA
| | - Barbara K. Burton
- Department of Pediatrics, Division of Genetics, Birth Defects & Metabolism, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL 60611 USA
| | - Celeste Decker
- BioMarin Pharmaceutical Inc, 105 Digital Drive, Novato, CA 94949 USA
| | - Mingjin Li
- BioMarin Pharmaceutical Inc, 105 Digital Drive, Novato, CA 94949 USA
| | - Kelly Lau
- BioMarin Pharmaceutical Inc, 105 Digital Drive, Novato, CA 94949 USA
| | - Joy Jiang
- BioMarin Pharmaceutical Inc, 105 Digital Drive, Novato, CA 94949 USA
| | - Kevin Larimore
- BioMarin Pharmaceutical Inc, 105 Digital Drive, Novato, CA 94949 USA
| | - Janet A. Thomas
- Department of Pediatrics, Section of Clinical Genetics and Metabolism, University of Colorado Hospital, 12605 E. 16th St, Aurora, CO 80045 USA
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Keshavarzi F, Rastegar M, Vessal M, Rafiei Dehbidi G, Khorsand M, Ganjkarimi AH, Takhshid MA. Serum ischemia modified albumin is a possible new marker of oxidative stress in phenylketonuria. Metab Brain Dis 2018; 33:675-680. [PMID: 29270710 DOI: 10.1007/s11011-017-0165-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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: 08/31/2016] [Accepted: 11/29/2017] [Indexed: 12/13/2022]
Abstract
The role of oxidative stress in the pathogenesis of phenylketonuria (PKU)-associated disorders has been implicated. Ischemia modified albumin (IMA) is a modified form of serum albumin, which is produced under the conditions of oxidative stress. The aim of this study was to measure the serum level of IMA in the PKU patients and to investigate its ability in predicting the status of oxidative stress in these patients. Fifty treated-PKU patients and fifty age- and sex-matched healthy subjects were included in the study. The blood samples were obtained and the serum level of phenylalanine (Phe) was measured using reverse phase HPLC method. The levels of IMA, malondialdehyde (MDA), gamma-glutamyl transferase (GGT) activity, and uric acid (UA) were determined using colorimetric methods. The levels of serum Phe, IMA, and MDA were significantly higher (p < 0.001) and the level of UA (p < 0.05) was lower in the PKU patients compared to control group. Serum IMA level was positively correlated with MDA (r = 0.585, p < 0.001) and UA (r = 0.6, p < 0.001). An inverse relationship was observed between the serum level of IMA and Phe (r = - 0.410, p < 0. 01). Results of the present study suggest that serum IMA level could be used as a novel marker for the evaluation of oxidative stress in the PKU patients.
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Affiliation(s)
- Fatemeh Keshavarzi
- Diagnostic Laboratory Sciences and Technology Research Center, School of Paramedical Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
- Fars Science and Research Branch, Islamic Azad University, Shiraz, Iran
| | - Mohsen Rastegar
- Diagnostic Laboratory Sciences and Technology Research Center, School of Paramedical Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahmood Vessal
- Fars Science and Research Branch, Islamic Azad University, Shiraz, Iran
| | - Gholamreza Rafiei Dehbidi
- Diagnostic Laboratory Sciences and Technology Research Center, School of Paramedical Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Marjan Khorsand
- Diagnostic Laboratory Sciences and Technology Research Center, School of Paramedical Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amir Hossein Ganjkarimi
- Diagnostic Laboratory Sciences and Technology Research Center, School of Paramedical Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Ali Takhshid
- Diagnostic Laboratory Sciences and Technology Research Center, School of Paramedical Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.
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Hasanzadeh M, Zargami A, Baghban HN, Mokhtarzadeh A, Shadjou N, Mahboob S. Aptamer-based assay for monitoring genetic disorder phenylketonuria (PKU). Int J Biol Macromol 2018; 116:735-743. [PMID: 29777816 DOI: 10.1016/j.ijbiomac.2018.05.028] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 05/05/2018] [Accepted: 05/05/2018] [Indexed: 11/20/2022]
Abstract
The genetic disorder phenylketonuria (PKU) is the inability to metabolize phenylalanine because of a lack of the enzyme phenylalanine hydroxylase. Phenylalanine is used to biochemically form proteins, coded for by DNA. The development of an apta-assay for detection of l-Phenylalanine is presented in this work. A highly specific DNA-aptamer, selected to l-Phenylalanine was immobilized onto a gold nanostructure and electrochemical measurements were performed in a solution containing the phosphate buffer solution with physiological pH. We have constructed an aptamer immobilized gold nanostructure mediated, ultrasensitive electrochemical biosensor (Apt/AuNSs/Au electrode) for l-Phenylalanine detection without any additional signal amplification strategy. The aptamer assemble onto the AuNSs makes Apt/AuNSs/Au electrode an excellent platform for the l-Phenylalanine detection in physiological like condition. Differential pulse voltammetry were used for the quantitative l-Phenylalanine detection. The Apt/AuNSs/Au electrode offers an ultrasensitive and selective detection of l-Phenylalanine down to 0.23 μM level with a wide dynamic range from 0.72 μM-6 mM. The aptasensor exhibited excellent selectivity and stability. The real sample analysis was performed by spiking the unprocessed human serum samples with various concentration of l-Phenylalanine and obtained recovery within 2% error value. The sensor is found to be more sensitive than most of the literature reports. The simple and easy way of construction of this apta-assay provides an efficient and promising diagnosis of phenylketonuria.
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Affiliation(s)
- Mohammad Hasanzadeh
- Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Amir Zargami
- Department of Biochemistry, Higher Education Institute of Rab-Rashid, Tabriz, Iran
| | - Hossein Navay Baghban
- Pharmaceutical Analysis Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ahad Mokhtarzadeh
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Nasrin Shadjou
- Department of Nanochemistry, Nano Technology Research Center, Uremia University, Uremia 57154, Iran
| | - Soltanali Mahboob
- Department of Biochemistry, Higher Education Institute of Rab-Rashid, Tabriz, Iran
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Václavík J, Coene KLM, Vrobel I, Najdekr L, Friedecký D, Karlíková R, Mádrová L, Petsalo A, Engelke UFH, van Wegberg A, Kluijtmans LAJ, Adam T, Wevers RA. Structural elucidation of novel biomarkers of known metabolic disorders based on multistage fragmentation mass spectra. J Inherit Metab Dis 2018; 41:407-414. [PMID: 29139026 DOI: 10.1007/s10545-017-0109-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 10/02/2017] [Accepted: 10/22/2017] [Indexed: 10/18/2022]
Abstract
Specific diagnostic markers are the key to effective diagnosis and treatment of inborn errors of metabolism (IEM). Untargeted metabolomics allows for the identification of potential novel diagnostic biomarkers. Current separation techniques coupled to high-resolution mass spectrometry provide a powerful tool for structural elucidation of unknown compounds in complex biological matrices. This is a proof-of-concept study testing this methodology to determine the molecular structure of as yet uncharacterized m/z signals that were significantly increased in plasma samples from patients with phenylketonuria and 3-hydroxy-3-methylglutaryl-CoA lyase deficiency. A hybrid linear ion trap-orbitrap high resolution mass spectrometer, capable of multistage fragmentation, was used to acquire accurate masses and product ion spectra of the uncharacterized m/z signals. In order to determine the molecular structures, spectral databases were searched and fragmentation prediction software was used. This approach enabled structural elucidation of novel compounds potentially useful as biomarkers in diagnostics and follow-up of IEM patients. Two new conjugates, glutamyl-glutamyl-phenylalanine and phenylalanine-hexose, were identified in plasma of phenylketonuria patients. These novel markers showed high inter-patient variation and did not correlate to phenylalanine levels, illustrating their potential added value for follow-up. As novel biomarkers for 3-hydroxy-3-methylglutaryl-CoA lyase deficiency, three positional isomers of 3-methylglutaconyl carnitine could be detected in patient plasma. Our results highlight the applicability of current accurate mass multistage fragmentation techniques for structural elucidation of unknown metabolites in human biofluids, offering an unprecedented opportunity to gain further biochemical insights in known inborn errors of metabolism by enabling high confidence identification of novel biomarkers.
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Affiliation(s)
- Jan Václavík
- Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacký University and University Hospital in Olomouc, Hněvotínská 5, 775 15, Olomouc, Czech Republic
- Laboratory of Inherited Metabolic Disorders, Department of Clinical Chemistry, University Hospital in Olomouc, I.P. Pavlova 6, 775 20, Olomouc, Czech Republic
| | - Karlien L M Coene
- Translational Metabolic Laboratory - 830 TML, Department of Laboratory Medicine, Radboud University Medical Centre, Geert Grooteplein 10, 6525, GA, Nijmegen, the Netherlands
| | - Ivo Vrobel
- Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacký University and University Hospital in Olomouc, Hněvotínská 5, 775 15, Olomouc, Czech Republic
- Laboratory of Inherited Metabolic Disorders, Department of Clinical Chemistry, University Hospital in Olomouc, I.P. Pavlova 6, 775 20, Olomouc, Czech Republic
| | - Lukáš Najdekr
- Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacký University and University Hospital in Olomouc, Hněvotínská 5, 775 15, Olomouc, Czech Republic
- Laboratory of Inherited Metabolic Disorders, Department of Clinical Chemistry, University Hospital in Olomouc, I.P. Pavlova 6, 775 20, Olomouc, Czech Republic
| | - David Friedecký
- Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacký University and University Hospital in Olomouc, Hněvotínská 5, 775 15, Olomouc, Czech Republic
- Laboratory of Inherited Metabolic Disorders, Department of Clinical Chemistry, University Hospital in Olomouc, I.P. Pavlova 6, 775 20, Olomouc, Czech Republic
| | - Radana Karlíková
- Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacký University and University Hospital in Olomouc, Hněvotínská 5, 775 15, Olomouc, Czech Republic
- Laboratory of Inherited Metabolic Disorders, Department of Clinical Chemistry, University Hospital in Olomouc, I.P. Pavlova 6, 775 20, Olomouc, Czech Republic
| | - Lucie Mádrová
- Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacký University and University Hospital in Olomouc, Hněvotínská 5, 775 15, Olomouc, Czech Republic
- Laboratory of Inherited Metabolic Disorders, Department of Clinical Chemistry, University Hospital in Olomouc, I.P. Pavlova 6, 775 20, Olomouc, Czech Republic
| | - Aleksanteri Petsalo
- Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacký University and University Hospital in Olomouc, Hněvotínská 5, 775 15, Olomouc, Czech Republic
| | - Udo F H Engelke
- Translational Metabolic Laboratory - 830 TML, Department of Laboratory Medicine, Radboud University Medical Centre, Geert Grooteplein 10, 6525, GA, Nijmegen, the Netherlands
| | - Annemiek van Wegberg
- Department of Gastroenterology, Radboud University Medical Centre, Geert Grooteplein 10, 6525, GA, Nijmegen, the Netherlands
| | - Leo A J Kluijtmans
- Translational Metabolic Laboratory - 830 TML, Department of Laboratory Medicine, Radboud University Medical Centre, Geert Grooteplein 10, 6525, GA, Nijmegen, the Netherlands
| | - Tomáš Adam
- Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacký University and University Hospital in Olomouc, Hněvotínská 5, 775 15, Olomouc, Czech Republic.
- Laboratory of Inherited Metabolic Disorders, Department of Clinical Chemistry, University Hospital in Olomouc, I.P. Pavlova 6, 775 20, Olomouc, Czech Republic.
| | - Ron A Wevers
- Translational Metabolic Laboratory - 830 TML, Department of Laboratory Medicine, Radboud University Medical Centre, Geert Grooteplein 10, 6525, GA, Nijmegen, the Netherlands
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Verduci E, Moretti F, Bassanini G, Banderali G, Rovelli V, Casiraghi MC, Morace G, Borgo F, Borghi E. Phenylketonuric diet negatively impacts on butyrate production. Nutr Metab Cardiovasc Dis 2018; 28:385-392. [PMID: 29502926 DOI: 10.1016/j.numecd.2018.01.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 01/12/2018] [Accepted: 01/15/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIMS Phenylalanine (Phe) restricted diet, combined with Phe-free l-amino acid supplementation, is the mainstay of treatment for phenylketonuria (PKU). Being the diet a key factor modulating gut microbiota composition, the aim of the present paper was to compare dietary intakes, gut microbiota biodiversity and short chain fatty acids (SCFAs) production in children with PKU, on low-Phe diet, and in children with mild hyperphenylalaninemia (MHP), on unrestricted diet. METHODS AND RESULTS We enrolled 21 PKU and 21 MHP children matched for gender, age and body mass index z-score. Dietary intakes, including glycemic index (GI) and glycemic load (GL), and fecal microbiota analyses, by means of denaturing gradient gel electrophoresis (DGGE) and Real-time PCR were assessed. Fecal SCFAs were quantified by gas chromatographic analysis. RESULTS We observed an increased carbohydrate (% of total energy), fiber and vegetables intakes (g/day) in PKU compared with MHP children (p = 0.047), as well a higher daily GI and GL (maximum p < 0.001). Compared with MHP, PKU showed a lower degree of microbial diversity and a decrease in fecal butyrate content (p = 0.02). Accordingly, two of the most abundant butyrate-producing genera, Faecalibacterium spp. and Roseburia spp., were found significantly depleted in PKU children (p = 0.02 and p = 0.03, respectively). CONCLUSION The low-Phe diet, characterized by a higher carbohydrate intake, increases GI and GL, resulting in a different quality of substrates for microbial fermentation. Further analyses, thoroughly evaluating microbial species altered by PKU diet are needed to better investigate gut microbiota in PKU children and to eventually pave the way for pre/probiotic supplementations.
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Affiliation(s)
- E Verduci
- Department of Pediatrics, San Paolo Hospital, Università degli Studi di Milano, Milan, Italy.
| | - F Moretti
- Department of Pediatrics, San Paolo Hospital, Università degli Studi di Milano, Milan, Italy
| | - G Bassanini
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - G Banderali
- Department of Pediatrics, San Paolo Hospital, Università degli Studi di Milano, Milan, Italy
| | - V Rovelli
- Department of Pediatrics, San Paolo Hospital, Università degli Studi di Milano, Milan, Italy
| | - M C Casiraghi
- Department of Food, Environmental and Nutritional Sciences, Università degli Studi di Milano, Milan, Italy
| | - G Morace
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - F Borgo
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - E Borghi
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
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Boot E, Hollak CEM, Huijbregts SCJ, Jahja R, van Vliet D, Nederveen AJ, Nieman DH, Bosch AM, Bour LJ, Bakermans AJ, Abeling NGGM, Bassett AS, van Amelsvoort TAMJ, van Spronsen FJ, Booij J. Cerebral dopamine deficiency, plasma monoamine alterations and neurocognitive deficits in adults with phenylketonuria. Psychol Med 2017; 47:2854-2865. [PMID: 28552082 DOI: 10.1017/s0033291717001398] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [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] [Indexed: 11/07/2022]
Abstract
BACKGROUND Phenylketonuria (PKU), a genetic metabolic disorder that is characterized by the inability to convert phenylalanine to tyrosine, leads to severe intellectual disability and other cerebral complications if left untreated. Dietary treatment, initiated soon after birth, prevents most brain-related complications. A leading hypothesis postulates that a shortage of brain monoamines may be associated with neurocognitive deficits that are observable even in early-treated PKU. However, there is a paucity of evidence as yet for this hypothesis. METHODS We therefore assessed in vivo striatal dopamine D2/3 receptor (D2/3R) availability and plasma monoamine metabolite levels together with measures of impulsivity and executive functioning in 18 adults with PKU and average intellect (31.2 ± 7.4 years, nine females), most of whom were early and continuously treated. Comparison data from 12 healthy controls that did not differ in gender and age were available. RESULTS Mean D2/3R availability was significantly higher (13%; p = 0.032) in the PKU group (n = 15) than in the controls, which may reflect reduced synaptic brain dopamine levels in PKU. The PKU group had lower plasma levels of homovanillic acid (p < 0.001) and 3-methoxy-4-hydroxy-phenylglycol (p < 0.0001), the predominant metabolites of dopamine and norepinephrine, respectively. Self-reported impulsivity levels were significantly higher in the PKU group compared with healthy controls (p = 0.033). Within the PKU group, D2/3R availability showed a positive correlation with both impulsivity (r = 0.72, p = 0.003) and the error rate during a cognitive flexibility task (r = 0.59, p = 0.020). CONCLUSIONS These findings provide further support for the hypothesis that executive functioning deficits in treated adult PKU may be associated with cerebral dopamine deficiency.
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Affiliation(s)
- E Boot
- Department of Nuclear Medicine,Academic Medical Center,Amsterdam,The Netherlands
| | - C E M Hollak
- Division of Endocrinology and Metabolism, Department of Internal Medicine,Academic Medical Center,Amsterdam,The Netherlands
| | - S C J Huijbregts
- Department of Clinical Child and Adolescent Studies & Leiden,Institute for Brain and Cognition, Leiden University,Leiden,The Netherlands
| | - R Jahja
- Division of Metabolic Diseases,University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital,Groningen,The Netherlands
| | - D van Vliet
- Division of Metabolic Diseases,University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital,Groningen,The Netherlands
| | - A J Nederveen
- Department of Radiology,Academic Medical Center,Amsterdam,The Netherlands
| | - D H Nieman
- Department of Psychiatry,Academic Medical Center,Amsterdam,The Netherlands
| | - A M Bosch
- Department of Pediatrics,Emma Children's Hospital, Academic Medical Center,Amsterdam,The Netherlands
| | - L J Bour
- Department of Neurology and Clinical Neurophysiology,Academic Medical Center,Amsterdam,The Netherlands
| | - A J Bakermans
- Department of Radiology,Academic Medical Center,Amsterdam,The Netherlands
| | - N G G M Abeling
- Laboratory for Genetic Metabolic Diseases,Academic Medical Center,Amsterdam,The Netherlands
| | - A S Bassett
- The Dalglish Family 22q Clinic for Adults with 22q11.2 Deletion Syndrome, andCenter for Mental Health, University Health Network,Toronto, Ontario,Canada
| | - T A M J van Amelsvoort
- Department of Psychiatry and Psychology,Maastricht University,Maastricht,The Netherlands
| | - F J van Spronsen
- Division of Metabolic Diseases,University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital,Groningen,The Netherlands
| | - J Booij
- Department of Nuclear Medicine,Academic Medical Center,Amsterdam,The Netherlands
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van Spronsen FJ, van Wegberg AM, Ahring K, Bélanger-Quintana A, Blau N, Bosch AM, Burlina A, Campistol J, Feillet F, Giżewska M, Huijbregts SC, Kearney S, Leuzzi V, Maillot F, Muntau AC, Trefz FK, van Rijn M, Walter JH, MacDonald A. Key European guidelines for the diagnosis and management of patients with phenylketonuria. Lancet Diabetes Endocrinol 2017; 5:743-756. [PMID: 28082082 DOI: 10.1016/s2213-8587(16)30320-5] [Citation(s) in RCA: 230] [Impact Index Per Article: 32.9] [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: 06/20/2016] [Revised: 09/11/2016] [Accepted: 09/28/2016] [Indexed: 12/14/2022]
Abstract
We developed European guidelines to optimise phenylketonuria (PKU) care. To develop the guidelines, we did a literature search, critical appraisal, and evidence grading according to the Scottish Intercollegiate Guidelines Network method. We used the Delphi method when little or no evidence was available. From the 70 recommendations formulated, in this Review we describe ten that we deem as having the highest priority. Diet is the cornerstone of treatment, although some patients can benefit from tetrahydrobiopterin (BH4). Untreated blood phenylalanine concentrations determine management of people with PKU. No intervention is required if the blood phenylalanine concentration is less than 360 μmol/L. Treatment is recommended up to the age of 12 years if the phenylalanine blood concentration is between 360 μmol/L and 600 μmol/L, and lifelong treatment is recommended if the concentration is more than 600 μmol/L. For women trying to conceive and during pregnancy (maternal PKU), untreated phenylalanine blood concentrations of more than 360 μmol/L need to be reduced. Treatment target concentrations are as follows: 120-360 μmol/L for individuals aged 0-12 years and for maternal PKU, and 120-600 μmol/L for non-pregnant individuals older than 12 years. Minimum requirements for the management and follow-up of patients with PKU are scheduled according to age, adherence to treatment, and clinical status. Nutritional, clinical, and biochemical follow-up is necessary for all patients, regardless of therapy.
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Affiliation(s)
- Francjan J van Spronsen
- Division of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.
| | - Annemiek Mj van Wegberg
- Division of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Kirsten Ahring
- Department of PKU, Kennedy Centre, Copenhagen University Hospital, Glostrup, Denmark
| | | | - Nenad Blau
- University Children's Hospital, Dietmar-Hoppe Metabolic Centre, Heidelberg, Germany; University Children's Hospital Zurich, Zurich, Switzerland
| | - Annet M Bosch
- Department of Paediatrics, Division of Metabolic Disorders, Academic Medical Centre, University Hospital of Amsterdam, Amsterdam, Netherlands
| | - Alberto Burlina
- Division of Inherited Metabolic Diseases, Department of Paediatrics, University Hospital of Padova, Padova, Italy
| | - Jaime Campistol
- Neuropaediatrics Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Francois Feillet
- Department of Pediatrics, Hôpital d'Enfants Brabois, CHU Nancy, Vandoeuvre les Nancy, France
| | - Maria Giżewska
- Department of Pediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology of the Developmental Age, Pomeranian Medical University, Szczecin, Poland
| | - Stephan C Huijbregts
- Department of Clinical Child and Adolescent Studies-Neurodevelopmental Disorders, Faculty of Social Sciences, Leiden University, Leiden, Netherlands
| | - Shauna Kearney
- Clinical Psychology Department, Birmingham Children's Hospital, Birmingham, UK
| | - Vincenzo Leuzzi
- Department of Pediatrics, Child Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Francois Maillot
- Internal Medicine Service, CHRU de Tours, François Rabelais University, Tours, France
| | - Ania C Muntau
- University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fritz K Trefz
- University Children's Hospital, Dietmar-Hoppe Metabolic Centre, Heidelberg, Germany
| | - Margreet van Rijn
- Department of Dietetics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - John H Walter
- Manchester Academic Health Sciences Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Anita MacDonald
- Dietetic Department, Birmingham Children's Hospital, Birmingham, UK
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Abstract
Since 2007, synthetic tetrahydrobiopterin (BH4) has been approved as a therapeutic option in BH4-responsive phenylketonuria (PKU) and since 2015 extended to infants younger than 4 years in Europe. The current definition of BH4 responsiveness relies on the observation of a 20% to 30% blood phenylalanine (Phe) decrease after BH4 administration, under nonstandardized conditions. By this definition, however, patients with the same genotype or even the same patients were alternatively reported as responsive or nonresponsive to the cofactor. These inconsistencies are troubling, as frustrating patient expectations and impairing cost-effectiveness of BH4-therapy. Here we tried a quantitative procedure through the comparison of the outcome of a simple Phe and a combined Phe plus BH4 loading in a series of infants with PKU, most of them harboring genotypes already reported as BH4 responsive. Under these ideal conditions, blood Phe clearance did not significantly differ after the 2 types of loading, and a 20% to 30% decrease of blood Phe occurred irrespective of BH4 administration in milder forms of PKU. Such early screening for BH4 responsiveness, based on a quantitative assay, is essential for warranting an evidence-based and cost-effective therapy in those patients with PKU eventually but definitely diagnosed as responsive to the cofactor.
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Affiliation(s)
- Francesco Porta
- Department of Pediatrics, University of Torino, Torino, Italy
| | - Marco Spada
- Department of Pediatrics, University of Torino, Torino, Italy
| | - Alberto Ponzone
- Department of Pediatrics, University of Torino, Torino, Italy
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Kör D, Yılmaz BŞ, Bulut FD, Ceylaner S, Mungan NÖ. Improved metabolic control in tetrahydrobiopterin (BH4), responsive phenylketonuria with sapropterin administered in two divided doses vs. a single daily dose. J Pediatr Endocrinol Metab 2017; 30:713-718. [PMID: 28593914 DOI: 10.1515/jpem-2016-0461] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Accepted: 04/06/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Phenylketonuria (PKU) often requires a lifelong phenylalanine (Phe)-restricted diet. Introduction of 6R-tetrahydrobiopterin (BH4) has made a huge difference in the diets of patients with PKU. BH4 is the co-factor of the enzyme phenylalanine hydroxylase (PAH) and improves PAH activity and, thus, Phe tolerance in the diet. A limited number of published studies suggest a pharmacodynamic profile of BH4 more suitable to be administered in divided daily doses. METHODS After a 72-h BH4 loading test, sapropterin was initiated in 50 responsive patients. This case-control study was conducted by administering the same daily dose of sapropterin in group 1 (n=24) as a customary single dose or in two divided doses in group 2 (n=26) over 1 year. RESULTS Mean daily consumption of Phe increased significantly after the first year of BH4 treatment in group 2 compared to group 1 (p<0.05). At the end of the first year of treatment with BH4, another dramatic difference observed between the two groups was the ability to transition to a Phe-free diet. Eight patients from group 2 and two from group 1 could quit dietary restriction. CONCLUSIONS When given in two divided daily doses, BH4 was more efficacious than a single daily dose in increasing daily Phe consumption, Phe tolerance and the ability to transition to a Phe-unrestricted diet at the end of the first year of treatment.
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Abstract
Phenylketonuria's (PKU) treatment based on low natural protein diet may affect homocysteine (Hcys) metabolic pathway. Hcys alteration may be related to the methylation of arginine to asymmetric dimethylarginine (ADMA) and symmetric dimethylarginine (SDMA), which both modify nitric oxide production. The aim of this work is to evaluate the status of Hcys formation methylation cycle and ADMA and SDMA levels in patients with PKU in order to establish a potential relationship.Forty-two early diagnosed PKU patients under dietary treatment and good adherence to their diets were enrolled in this cross-sectional study. Their nutritional and biochemical profile, as well as Hcys synthesis status, ADMA and SDMA levels were analyzed and compared with a control group of 40 healthy volunteers. ADMA and SDMA were determined by high-performance liquid chromatography system coupled to triple quadrupole mass spectrometer.In this study, 23 classic PKU, 16 moderate PKU, and 3 mild HPA were enrolled. The median age was 10 years old. Median ADMA, SDMA, and Hcys concentration levels (5.1 μM [2.3-25.7], 0.35 μM [0.18-0.57], 0.43 μM [0.26-0.61], respectively) were lower in patients with PKU (P < .001 for ADMA and SDMA) whereas vitamin B12 and folate levels (616 pg/mL [218-1943] and 21 ng/mL [5-51], respectively) were higher comparing with controls. Statistically significant correlations were found between ADMA, and Phe (r = -0.504, P = .001) and Hcys (r = -0.458, P = .037) levels. Several nutrition biomarkers, such as prealbumin, 25-hydroxy vitamin D, selenium, and zinc, were below the normal range.Our study suggests that patients with PKU suffer from poor methylation capacity. Restriction of natural proteins in addition to high intake of vitamin B12 and folic acid supplementation in the dietary products, produce an impairment of methylation cycle that leads to low Hcys and ADMA levels. As a result, methylated compounds compete for methyl groups, and there is an impairment of methylation cycle due to low Hcys levels, which is related to the lack of protein quality, despite of elevated concentrations of cofactors.
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Affiliation(s)
- Fernando Andrade
- Unit of Metabolism, BioCruces Health Research Institute, CIBER de Enfermedades Raras (CIBERER), Barakaldo
| | - Olalla López-Suárez
- Metabolic Disorders Unit, Santiago de Compostela University Hospital, IDIS, CIBERER, Santiago de Compostela, Spain
| | - Marta Llarena
- Unit of Metabolism, BioCruces Health Research Institute, CIBER de Enfermedades Raras (CIBERER), Barakaldo
| | - María L. Couce
- Metabolic Disorders Unit, Santiago de Compostela University Hospital, IDIS, CIBERER, Santiago de Compostela, Spain
| | - Luis Aldámiz-Echevarría
- Unit of Metabolism, BioCruces Health Research Institute, CIBER de Enfermedades Raras (CIBERER), Barakaldo
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