Fibroblast growth factor 21 as a biomarker for long-term complications in organic acidemias.

BACKGROUND: There is increasing evidence that long-term complications in organic acidemias are caused by impaired mitochondrial metabolism. Currently, there is no specific biomarker to monitor mitochondrial dysfunction in organic acidemias. Serum fibroblast growth factor 21 (FGF-21) is a biomarker for mitochondrial disease and could be a candidate to monitor mitochondrial function in the deleterious course of disease. METHODS: Data of 17 patients with classical organic acidemias (11 propionic acidemia (PA), four methylmalonic acidemia (MMA) and two isovaleric acidemia (IVA) patients) were included. The clinical course was evaluated; metabolic decompensations and long-term complications were correlated with plasma FGF-21 levels. Cardiomyopathy, prolonged QT interval, renal failure, and optic neuropathy were defined as long-term complications. RESULTS: Patients ages ranged from 16 months up to 32 years. Serious long-term complications occurred in eight patients (five PA and three MMA patients). In MMA and PA patients plasma FGF-21 levels during stable metabolic periods were significantly higher in patients with long-term complications (Mdn = 2556.0 pg/ml) compared to patients without (Mdn = 287.0 pg/ml). A median plasma FGF-21 level above 1500 pg/ml during a stable metabolic period, measured before the occurrence of long-term complications, had a positive predictive value of 0.83 and a negative predictive value of 1.00 on long-term complications in MMA and PA patients. CONCLUSION: This study demonstrates the potential role of FGF-21 as a biomarker for long-term complications in classical organic acidemias, attributed to mitochondrial dysfunction.

Polyhydramnios and cerebellar atrophy: a prenatal presentation of mitochondrial encephalomyopathy caused by mutations in the FBXL4 gene.

Severe recessive mitochondrial myopathy caused by FBXL4 gene mutations may present prenatally with polyhydramnios and cerebellar hypoplasia. Characteristic dysmorphic features are: high and arched eyebrows, triangular face, a slight upslant of palpebral fissures, and a prominent pointed chin. Metabolic investigations invariably show increased serum lactate and pyruvate levels.

Pilot Experience with an External Quality Assurance Scheme for Acylcarnitines in Plasma/Serum.

The analysis of acylcarnitines (AC) in plasma/serum is established as a useful test for the biochemical diagnosis and the monitoring of treatment of organic acidurias and fatty acid oxidation defects. External quality assurance (EQA) for qualitative and quantitative AC is offered by ERNDIM and CDC in dried blood spots but not in plasma/serum samples. A pilot interlaboratory comparison between 14 European laboratories was performed over 3 years using serum/plasma samples from patients with an established diagnosis of an organic aciduria or fatty acid oxidation defect. Twenty-three different samples with a short clinical description were circulated. Participants were asked to specify the method used to analyze diagnostic AC, to give quantitative data for diagnostic AC with the corresponding reference values, possible diagnosis, and advice for further investigations.Although the reference and pathological concentrations of AC varied among laboratories, elevated marker AC for propionic acidemia, isovaleric acidemia, medium-chain acyl-CoA dehydrogenase, very long-chain acyl-CoA dehydrogenase, and multiple acyl-CoA dehydrogenase deficiencies were correctly identified by all participants allowing the diagnosis of these diseases. Conversely, the increased concentrations of dicarboxylic AC were not always identified, and therefore the correct diagnosis was not reach by some participants, as exemplified in cases of malonic aciduria and 3-hydroxy-3-methylglutaryl-CoA lyase deficiency. Misinterpretation occurred in those laboratories that used multiple-reaction monitoring acquisition mode, did not derivatize, or did not separate isomers. However, some of these laboratories suggested further analyses to clarify the diagnosis.This pilot experience highlights the importance of an EQA scheme for AC in plasma.

Cystathionine Levels in Patients With Huntington Disease.

BACKGROUND: Recently a profound depletion of cystathionine γ-lyase (CSE), the principal enzyme involved in the generation of cysteine from cystathionine, was shown in Huntington disease (HD) patients and several transgenic HD mouse models. We therefore hypothesized that blood and urine cystathionine levels may be increased in HD patients and that this increase might correlate with disease progression. METHODS: We measured concentrations of cystathionine as well as 22 other amino acids in fasting plasma and 24-h urine samples of nine early-stage HD patients and nine age, sex, and body mass index matched controls. RESULTS: There were no significant differences in the plasma or urine concentrations of cystathionine or any other amino acid between HD patients and controls. CONCLUSION: We found no evidence for changes in plasma or urine concentrations of cystathionine in early-stage HD patients. Therefore, cystathionine levels are unlikely to be useful as a state biomarker in HD.

Persistent 5-oxoprolinuria with normal glutathione synthase and 5-oxoprolinase activities.

5-Oxoprolinuria is primarily associated with inborn errors of the gamma-glutamyl cycle. In addition, transient 5-oxoprolinuria has been reported to occur in a variety of conditions, such as prematurity and malnutrition, and during medication. We report an unusual case of permanent 5-oxoprolinuria. The patient presented 3 days after birth with acidosis, and metabolic screening revealed massive excretion of 5-oxoproline. Following recovery, growth and psychomotor development were normal, but 5-oxoprolinuria persisted. Primary defects in the gamma-glutamyl cycle were ruled out since glutathione synthase and 5-oxoprolinase activities were normal. All known secondary causes of 5-oxoprolinuria were also excluded, leaving the basis of the permanent 5-oxoprolinuria in this patient unresolved.

Gut permeability in paediatric cardiac surgery.

BACKGROUND: Intestinal mucosal ischaemia can occur in infants and children during and after cardiac surgery. Severe decreases in mucosal perfusion may cause complications such as necrotizing enterocolitis and postoperative mortality. We investigated gut permeability in paediatric patients undergoing cardiac surgery using the dual sugar permeability test and absorption of two other saccharides. METHODS: Thirty-four patients undergoing palliative or corrective surgical procedures with and without cardiopulmonary bypass were investigated. Intestinal permeability was measured using 3-O-methyl-D-glucose, D-xylose, L-rhamnose and lactulose, given orally after induction of anaesthesia and 12 and 24 h later. RESULTS: Lactulose/rhamnose ratios were raised from the outset [median 0.39 (confidence interval 0.07-1.8 for patients undergoing operations without cardiopulmonary bypass and 0.30 (0.02-2.6) with cardiopulmonary bypass]. The highest lactulose/rhamnose ratios were recorded 12 h after surgery 0.32 (0.07-6.9), when cardiopulmonary bypass was used. This is approximately seven times the value expected in healthy children. There was an improvement in patients not undergoing cardiopulmonary bypass: 0.22 (0.03-0.85) 12 h and 0.11 (0-0.48) 24 h after induction of anaesthesia. Patients undergoing repair of aortic coarctation showed the fastest recovery: 0.09 (0.03-0.31) 12 h and 0.07 (0.04-0.35) 24 h after induction of anaesthesia. CONCLUSIONS: Patients with congenital heart defects have abnormal gut permeability when compared with healthy children of similar age. Cardiopulmonary bypass seems to affect the intestinal barrier morphologically (lactulose and rhamnose absorption) and functionally (3-O-methyl-D-glucose and D-xylose absorption).

GLUT-1 deficiency without epilepsy--an exceptional case.

The GLUT-1 deficiency is a metabolic disorder caused by a defect in glucose transport across the blood-brain barrier as a result of a defect in the glucose-transport protein. Patients present with epileptic seizures, delayed development, ataxia and hypotonia, and in many cases acquired microcephaly. In most patients, treatment with a ketogenic diet proved to be successful in controlling the epilepsy. We report a 9-year-old boy with retardation and ataxia, but without epilepsy, caused by GLUT-1 deficiency, proven biochemically and by DNA analysis. Treatment with a medium-chain triglyceride ketogenic diet had a beneficial effect.

L-Arabinosuria: a new defect in human pentose metabolism.

A female patient, the first child of healthy non-consanguineous parents, presented at the age of 16 months with delayed motor development and facial dysmorphism. In addition she displayed a palatoschizis and multiple skeletal abnormalities as hypoplastic scapulae, hypoplastic os ilea, and an extreme cervical kyphosis. Biochemical investigation of urine revealed no abnormalities except for the presence of large amounts of reducing sugars. The sugar was identified as L-arabinose, which mainly originated from fruit formula in her diet. In addition highly elevated levels of L-arabitol were found in urine, plasma, and cerebrospinal fluid. Although little is known about human arabinose metabolism, we presume that L-arabitol dehydrogenase is deficient in our patient. As polyols are potentially toxic to the central nervous system there could be deleterious long-term effects of this disorder. Withdrawal of dietary fruit led to normalization of polyol levels. The above-mentioned clinical abnormalities are probably not related to this new inborn error of metabolism and should be considered as a separate entity.

Intermediates of unsaturated fatty acid oxidation are incorporated in triglycerides but not in phospholipids in tissues from patients with mitochondrial beta-oxidation defects.

The fatty acid composition was determined of liver, skeletal muscle and heart obtained post mortem from patients with medium-chain acyl-CoA dehydrogenase deficiency (MCADD), multiple acyl-CoA dehydrogenase deficiency (MADD) and very long-chain acyl-CoA dehydrogenase deficiency (VLCADD). Increased amounts of 4-decenoic acid 10:1(n-6), 5-dodecenoic acid 12:1(n-7), 5-tetradecenoic acid 14:1(n-9), 5,8-tetradecadienoic acid 14:2(n-6) and 7,10-hexadecadienoic acid 16:2(n-6)--intermediates of unsaturated fatty acid oxidation--were found. Fractionation into different lipid classes showed that these fatty acids were exclusively present in the triglyceride fraction. They could not be detected in the free fatty acid fraction or in the phospholipid fraction. Our results suggest that intermediates of unsaturated fatty acid oxidation that accumulate as a consequence of MCADD, MADD and VLCADD are transported to the endoplasmic reticulum for esterification into neutral glycerolipids. The pattern of accumulation is characteristic for each disease, which makes fatty acid analysis of total lipid of post-mortem tissues a useful tool in the detection of mitochondrial fatty acid oxidation defects in patients who died unexpected, for example with sudden infant death syndrome.

Effect of intraduodenal and intravenous amino acids on proximal gastric motor function in man.

The present study was performed to investigate the effect of amino acids during the intestinal and postabsorptive phase of digestion on proximal gastric motor function measured with an electronic barostat. Eight healthy volunteers participated in three experiments performed during continuous infusion of: (1) intravenous and intraduodenal saline, (2) intraduodenal amino acids, and (3) intravenous amino acids. Both intraduodenal and intravenous amino acids induced gastric relaxation and increased gastric compliance. Only during intraduodenal amino acids did plasma CCK levels increase significantly. Correlation between intragastric volume measurements (with pressure set at MDP + 2 mm Hg) and plasma CCK levels was 0.90 (P < 0.001) during the early intestinal phase. Relaxation of the proximal stomach is related to plasma CCK in the early intestinal phase, whereas in the postabsorptive phase of amino acids other mechanisms play a role in proximal gastric relaxation.

Normal oxidative stress and enhanced lipoprotein resistance to in vitro oxidation in hypertriglyceridemia: effects of bezafibrate therapy.

Although there is evidence that hyperlipidemia and predominance of small dense low density lipoproteins (LDLs) are associated with increased oxidative stress, the oxidation status in patients with hypertriglyceridemia (HTG) has not been studied in detail. Therefore, we studied urinary levels of F(2)-isoprostanes (8-isoprostaglandin F(2alpha) and 2,3-dinor-5,6-dihydro-8-isoprostaglandin F(2alpha)) and susceptibility of very low density lipoproteins (VLDLs) and LDLs to oxidation ex vivo in 18 patients with endogenous HTG and 20 matched control subjects. In addition, the effects of 6 weeks of bezafibrate therapy were assessed in a double-blind, placebo-controlled, crossover trial. Urinary levels of F(2)-isoprostanes were similar in the HTG and normolipidemic group. Bezafibrate caused an increase in 8-isoprostaglandin F(2alpha) (762+/-313 versus 552+/-245 ng/24 h for bezafibrate and placebo therapy, respectively; P=0.03), whereas 2,3-dinor-5, 6-dihydro-8-isoprostaglandin F(2alpha) levels tended to be increased (1714+/-761 versus 1475+/-606 ng/24 h for bezafibrate and placebo therapy, respectively; P=0.11). VLDLs and LDLs were more resistant to copper-induced oxidation in patients with HTG than in control subjects. Bezafibrate reversed the oxidation resistance to the normal range. In conclusion, these results indicate the following: (1) HTG is associated with normal in vivo oxidative stress and enhanced ex vivo resistance of lipoproteins to oxidation. (2) Bezafibrate reduces the resistance of lipoproteins to copper-induced oxidation and enhances oxidative stress in HTG patients.

Effect of L-arginine on lower oesophageal sphincter motility in man.

OBJECTIVE: Inhibitory responses of the lower oesophageal sphincter (LOS) are mediated via an L-arginine/nitric oxide (NO) pathway. L-arginine is known as the precursor of NO. We have studied the effect of intravenous L-arginine on LOS motility in man. DESIGN: Twelve healthy subjects participated in a double-blind, placebo-controlled randomized study. METHODS: We investigated the effect of continuous infusion of L-arginine (500 mg/kg body weight/120 min) in six subjects under fasting conditions. Six other subjects were studied under postprandial conditions. LOS pressure (LOSP), swallow-induced LOS relaxations and transient lower oesophageal sphincter relaxations (TLOSR) were measured with sleeve manometry combined with pH metry. The meal consisted of a carbohydrate-high fat meal. Blood samples were taken before and after administration of L-arginine or saline to determine plasma levels of amino acids, cholecystokinin and gastrin. RESULTS: Plasma levels of arginine and citrulline significantly (P < 0.05) increased during L-arginine infusion. L-arginine did not affect plasma hormone levels. Under fasting conditions, LOSP and TLOSR were not influenced by L-arginine. Ingestion of the carbohydrate-high fat meal significantly decreased LOSP. L-arginine did not significantly influence TLOSR frequency, either under fasting conditions or postprandially. CONCLUSIONS: These results suggest that in humans under fasting or postprandial conditions intravenous infusion of L-arginine does not influence LOS motility.

Mental retardation and behavioral problems as presenting signs of a creatine synthesis defect.

Recently, 3 patients with a creatine synthesis defect have been described. They presented with developmental regression, extrapyramidal movement abnormalities, and intractable epilepsy, and they improved with treatment of creatine monohydrate. We report 2 unrelated boys with a creatine synthesis defect and nonspecific presenting signs of psychomotor retardation, behavioral problems, and, in 1, mild epilepsy. Metabolic urine screening revealed elevations in all metabolites, expressed as millimoles per mole of creatinine, which suggests decreased creatinine excretion. This finding led to the correct diagnosis. We propose to include the assessment of the overall concentrations of amino acids and organic acids relative to creatinine in routine metabolic urine screening.

Dietary counselling effectively improves lipid levels in patients with endogenous hypertriglyceridemia: emphasis on weight reduction and alcohol limitation.

OBJECTIVE: To evaluate the short-term effect of dietary counselling in patients with endogenous hypertriglyceridemia and evaluate the effects of advised nutrient changes. DESIGN: A prospective dietary intervention study in patients with endogenous hypertriglyceridemia from January I st 1988 to December 31 st 1996 according to the Dutch guidelines for a healthy diet. Before and after the dietary intervention period of 12 weeks, 24h food recalls were used to assess dietary intake and macronutrient composition. Effectiveness was evaluated by assessment of body weight, serum lipids, lipoproteins and insulin resistance parameters. SETTING: Leiden outpatient Lipid Clinic. SUBJECTS: Forty-five newly diagnosed, untreated patients with endogenous hypertriglyceridemia. RESULTS: A significant reduction in energy intake and body weight as well as changes in macronutrient composition were observed. Total serum triacylglycerol and cholesterol levels decreased by 31% and 15%, respectively. No effects were observed on serum glucose and insulin levels. Weight reduction was significantly correlated with reduction of total plasma triacylglycerol levels and inversely correlated with changes in HDL cholesterol levels. Of all nutrients assessed, only reduction of alcohol intake correlated with improvement of total serum triacylglycerol. CONCLUSIONS: Short-term dietary counselling in patients with endogenous hypertriglyceridemia can effectively improve serum lipid and lipoprotein levels. With regard to the advised nutrient changes, weight loss and limitation of alcohol intake prove to be the best predictors of triacylglycerol reduction.

Effect of i.v. amino acids on satiety in humans.

BACKGROUND: Parenteral nutrients suppress oral food intake. Separate i.v. infusion of amino acids (IVAA) at high doses affects gastrointestinal motility and secretion. However, little is known on the effects of separate i.v. infusion of amino acids at these high doses on satiety. Therefore, we have studied the effect of two different doses of a commercially available mixed amino acids solution on satiety and food intake. METHODS: Six healthy volunteers (ages 20 to 34 years) were studied on three separate occasions in random order during (a) i.v. saline (control), (b) low-dose IVAA ([LDA] 125 mg protein/kg/h, Vamin 18EF; Kabi Pharmacia BV, Woerden, The Netherlands), or (c) high-dose IVAA ([HDA] 250 mg protein/kg/h) for 360 minutes. Subjective criteria such as wish to eat, prospective feeding intentions, and feelings of hunger and fullness were scored on 100-mm visual analog scales at 30-minute intervals. Food preference also was measured every 60 minutes with food selection lists. At the end of the experiment a meal was presented. RESULTS: Feelings of fullness were significantly (p < .05) increased during both LDA and HDA. The wish to eat was significantly (p < .05) decreased during HDA compared with control and LDA. Prospective feeding intentions also tended to be reduced during HDA (not significant). Feelings of hunger were not significantly different between the three experiments. Total food selection was significantly (p < .05) decreased during LDA and HDA, mainly because of a significantly (p < .05) decreased preference for fat-rich items. However, the total amount of food consumed at the end of the experiment was not significantly different between the three experiments. CONCLUSIONS: The present study shows that in healthy volunteers, IVAA (1) increase satiety ratings, (2) increase feelings of fullness, (3) decrease preprandial food selection, and (4) have no effect on subsequent oral food intake.

Effect of intravenous amino acids on interdigestive antroduodenal motility and small bowel transit time.

BACKGROUND: Patients on total parenteral nutrition have an increased risk of developing gallstones because of gall bladder hypomotility. High dose amino acids may prevent biliary stasis by stimulating gall bladder emptying. AIMS: To investigate whether intravenous amino acids also influence antroduodenal motility. METHODS: Eight healthy volunteers received, on three separate occasions, intravenous saline (control), low dose amino acids (LDA), or high dose amino acids (HDA). Antroduodenal motility was recorded by perfusion manometry and duodenocaecal transit time (DCTT) using the lactulose breath hydrogen test. RESULTS: DCTT was significantly prolonged during LDA and HDA treatment compared with control. The interdigestive motor pattern was maintained and migrating motor complex (MMC) cycle length was significantly reduced during HDA compared with control and LDA due to a significant reduction in phase II duration. Significantly fewer phase IIIs originated in the gastric antrum during LDA and HDA compared with control. Duodenal phase II motility index was significantly reduced during HDA, but not during LDA, compared with control. CONCLUSIONS: Separate intravenous infusion of high doses of amino acids in healthy volunteers: (1) modulates interdigestive antroduodenal motility; (2) shortens MMC cycle length due to a reduced duration of phase II with a lower contractile incidence both in the antrum and duodenum (phase I remains unchanged whereas the effect on phase III is diverse: in the antrum phase III is suppressed and in the duodenum the frequency is increased); and (3) prolongs interdigestive DCTT.

Very long chain acyl-coenzyme A dehydrogenase deficiency with adult onset.

Very long chain acyl-coenzyme A (acyl-CoA) dehydrogenase (VLCAD) deficiency is a severe disorder of mitochondrial beta-oxidation in infants. We report adult onset of attacks of painful rhabdomyolysis. Gas chromatography identified strongly elevated levels of tetradecenoic acid, 14:1(n-9), tetradecadienoic acid, 14:2(n-6), and hexadecadienoic acid, 16:2(n-6). Palmitoyl-CoA and behenoyl-CoA dehydrogenase in fibroblasts were deficient. Muscle VLCAD activity was very low. DNA analysis revealed compound heterozygosity for two missense mutations in the VLCAD gene. The relatively mild clinical course may be due to residual enzyme activity as a consequence of the two missense mutations. Treatment with L-carnitine and medium chain triglycerides in the diet did not reduce the attacks of rhabdomyolysis.

Psychological and metabolic responses of carbohydrate craving obese patients to carbohydrate, fat and protein-rich meals.

RATIONALE: A defective central serotonergic neurotransmission has been suggested to result in the concomitant occurrence of an appetite disorder and a disturbed mood. This syndrome was termed carbohydrate carving (CC) obesity. Excessive consumption of carbohydrate-rich snacks would, through a plasma amino acid mediated mechanism, restore serotonergic neurotransmission and thereby relieve the symptoms of atypical depression. OBJECTIVES: To test whether CC obese patients indeed exhibit symptoms of atypical depression, whether these symptoms can be alleviated by carbohydrate-rich snacks and whether they respond differently to the snacks than non-carbohydrate craving (NC) control subjects. Furthermore, we investigated whether differences between CC and NC patients could be related to peripheral metabolic differences. DESIGN: Double blinded, randomized with cross-over. Patients received three types of snacks (100/0/0, 70/29/1 and 35/3/62 energy percent carbohydrate/fat/protein respectively) on three consecutive test days. Before and after snack administration mood and performance were tested and blood samples were obtained. SUBJECTS: 9 CC and 17 NC obese patients, matched for sex, age and body mass index. MEASUREMENTS: Mood states (Profile of Mood States and Visual Analogue Scales) and performance (Bourdon-Wiersma cancellation test), serum glucose and insulin and plasma amino acid concentrations. RESULTS: Before snack consumption, CC patients had slightly higher anger and fatigue scores and tended to have lower mood scores than NC patients. The efficiency of performance increased in both groups after all snacks. No other psychological effects of the snacks were registered. Psychological and metabolic responses of CC and NC patients to the snacks were similar. CONCLUSION: Although they may have a somewhat disturbed mood, CC obese patients do not improve their mood states through ingestion of a carbohydrate-rich snack. It seems, from a therapeutic point of view, useless to maintain the concept of carbohydrate craving.