Inborn Errors Of Urea Synthesis Research Articles

Perspectives on urea cycle disorder management: Results of a clinician survey

Background/AimsUrea cycle disorders (UCDs) are rare inborn errors of urea synthesis. US and European consensus statements on the diagnosis and treatment of UCDs were last published in 2001 and 2019, respectively. Recommendations are based primarily on case reports and expert opinion and there is limited agreement or consistency related to long-term management approaches. A clinician survey was conducted to assess current real-world practices and perspectives on challenges and unmet needs. MethodsA 14-item multiple-choice survey was administered to physicians in 2017. Clinicians who reported actively managing at least 1 patient with UCD were eligible to participate. Descriptive statistics were calculated for each survey item (frequencies for categorical variables; means, standard deviations, medians, and ranges for continuous variables). ResultsSixty-six US clinicians completed the survey (65 geneticists; 1 pediatric neurologist). Over 90% of responders agreed or strongly agreed that even modest elevations in ammonia could cause physiological and functional brain damage; >80% of respondents agreed that asymptomatic UCD patients are at risk of brain damage over time due to mild/subclinical elevations in ammonia. Eighty-six percent of clinicians agreed or strongly agreed with recommending genetic testing for female relatives when a patient is diagnosed with ornithine transcarbamylase deficiency. Ninety-four percent of respondents agreed that patients have better disease control when they are more adherent to their UCD therapy. Nearly 90% indicated that clinicians and patients would benefit from updated UCD management guidance. More than half (53%) of respondents rated the symptoms of UCDs as extremely or very burdensome to the everyday lives of patients and their families; only 8% rated UCD symptoms as slightly or not at all burdensome. The majority of clinicians agreed (48%) or strongly agreed (32%) that caring for a child or family member with a UCD has a negative impact on the quality of life and/or health of family members/guardians (e.g. stress, relationships, ability to work). ConclusionsThis self-reported survey suggests a need for updated and expanded clinical guidance on the long-term treatment and management of UCD patients.

Simultaneous LC‐MS/MS determination of phenylbutyrate, phenylacetate benzoate and their corresponding metabolites phenylacetylglutamine and hippurate in blood and urine

Inborn errors of urea metabolism result in hyperammonemia. Treatment of urea cycle disorders can effectively lower plasma ammonium levels and results in survival in the majority of patients. Available medications for treating urea cycle disorders include sodium benzoate (BA), sodium phenylacetate (PAA), and sodium phenylbutyrate (PBA) and are given to provide alternate routes for disposition of waste nitrogen excretion. In this study, we develop and validate a liquid chromatography tandem mass spectrometry (LC-MS/MS) method for simultaneous determination of benzoic acid, phenylacetic acid, phenylbutyric acid, phenylacetylglutamine, and hippuric acid in plasma and urine from children with inborn errors of urea synthesis. Plasma extracts and diluted urine samples were injected on a reverse-phase column and identified and quantified by selected reaction monitoring (SRM) in negative ion mode. Deuterated analogues served as internal standards. Analysis time was 7 min. Assay precision, accuracy, and linearity and sample stability were determined using enriched samples. Quantification limits of the method were 100 ng/ml (0.3-0.8 μmol/L) for all analytes, and recoveries were >90%. Inter- and intraday relative standard deviations were <10%. Our newly developed LC-MS/MS represents a robust, sensitive, and rapid method that allows simultaneous determination of the five compounds in plasma and urine.

Intellectual, adaptive, and behavioral functioning in children with urea cycle disorders.

Inborn errors of urea synthesis lead to an accumulation of ammonia in blood and brain and result in high rates of mortality and neurodevelopmental disability. This study seeks to characterize the cognitive, adaptive, and emotional/behavioral functioning of children with urea cycle disorders (UCDs). These domains were measured through testing and parent questionnaires in 92 children with UCDs [33 neonatal onset (NO), 59 late onset (LO)]. Results indicate that children who present with NO have poorer outcome than those who present later in childhood. Approximately half of the children with NO performed in the range of intellectual disability (ID), including a substantial number ( approximately 30%) who were severely impaired. In comparison, only a quarter of the LO group was in the range of ID. There is also evidence that the UCD group has difficulties in aspects of emotional/behavioral and executive skills domains. In conclusion, children with UCDs present with a wide spectrum of cognitive outcomes. Children with NO disease have a much higher likelihood of having an ID, which becomes even more evident with increasing age. However, even children with LO UCDs demonstrate evidence of neurocognitive and behavioral impairment, particularly in aspects of attention and executive functioning.

Rare disease clinical research center for inborn errors of urea synthesis and related disorders

Rare disease clinical research center for inborn errors of urea synthesis and related disorders

Effect of pantothenic acid on hippurate formation in sodium benzoate-treated HepG2 cells.

Inborn errors of urea synthesis result in hyperammonemia. Sodium benzoate (SB) therapy has been beneficial in the treatment of hyperammonemia. It conjugates with glycine to form hippurate, which is then excreted. SB has also been used to treat children with nonketotic hyperglycinemia (NKH), where glycine is removed, on conjugation, as hippurate. In mammalian liver mitochondria, SB is activated by an ATP-dependent reaction to its CoA ester, before conjugation with glycine. Pantothenic acid (PA) is the precursor of CoA. In this investigation, increasing the amounts of PA increased CoA levels in HepG2 cells. It also significantly increased formation of hippurate in SB-treated cells. These findings suggest a beneficial effect of PA on the SB therapy in children with NKH as well as hyperammonemia.

Chronic Sodium Benzoate Therapy in Children with Inborn Errors of Urea Synthesis: Effect on Carnitine Metabolism and Ammonia Nitrogen Removal

Sodium benzoate (SB) therapy is known to increase ammonia (NH3) nitrogen elimination via conjugation with glycine and excretion as urinary hippurate. In 16 children with inborn errors of urea synthesis we studied two issues: (1) the effect of chronic SB administration upon carnitine metabolism and (2) the efficacy of chronic SB therapy as measured by the molar ratio of hippurate excretion to SB intake. Measurements were performed during elective hospitalizations when the patients were in stable metabolic condition. We found that chronic SB therapy is not associated with a constant level of hippurate elimination and that interindividual and intraindividual variability may result in irregular removal of NH3nitrogen. This variability may be due to various factors including the formation of small quantities of benzoylcarnitine, which was detected in the plasma of three of four patients receiving SB and carnitine therapy and in one of two patients on SB therapy without carnitine supplementation. The ratios of acyl to free carnitine were elevated in both plasma and urine in patients not receiving carnitine supplementation, but were normal in patients receiving supplementation.

Evidence of excitotoxicity in the brain of the ornithine carbamoyltransferase deficient sparse fur mouse

Ornithine carbamoyltransferase deficiency (OCTD) is the most common inborn error of urea synthesis. An X-linked disorder, OCTD males commonly present with hyperammonemic coma in the newborn period. There is a high rate of mortality and morbidity, with most survivors sustaining severe brain damage and resultant developmental disabilities. Although ammonia is presumed to be the principal neurotoxin, there is evidence that other neurochemical alterations may also be involved. The OCTD sparse fur ( spf/Y) mouse has proven to be a useful model of this disease with similar metabolic and neurochemical alterations to those found in the human disease. In this study, the levels of the tryptophan derived excitotoxin quinolinic acid were examined in the brains of spf/Y mice. In addition, the neuropathology was examined using both light and electron microscopic approaches. Consistent with reports in children with urea cycle disorders, the levels of tryptophan and quinolinic acid were increased two-fold in various brain regions of the spf/Y mouse. Quinolinic acid, an agonist at the N-methyl- d-aspartate (NMDA) receptors, is known to produce selective cell loss in the striatum. We found a significant loss of medium spiny neurons and increased numbers of reactive oligodendroglia and microglia in the striatum of spf/Y mice. These neurochemical and neuropathological observations are consistent with an excitotoxic influence on brain injury in OCTD. It leads us to suggest that administration of NMDA receptor antagonists may ameliorate brain damage in children with inborn errors of urea synthesis.

Prospects for gene therapy in ornithine carbamoyltransferase deficiency and other urea cycle disorders

AbstractAlthough individually inborn errors of metabolism are rare, collectively they contribute significantly to morbidity and mortality in the pediatric age group. There are several reasons why, out of these inborn errors of metabolism, urea cycle disorders have emerged as potentially good candidates for the development of gene therapy. Studies have initially focused on ornithine carbamoyltransferase (OCT) deficiency in part because there are mouse models of this disease and in part because this disease is particularly resistant to current therapies. Both in vivo and ex vivo approaches to gene therapy are being developed for the treatment of urea cycle disorders. Ex vivo gene therapy is appealing because of the long‐term expression that can be achieved, but there are clear limitations to this approach. In vivo gene therapy using adenoviral vectors is attractive for several reasons, including the fact that the virus can be administered by intravenous injection, the high levels of expression observed after a single injection, and the rapidity of that expression. Studies of transgene expression in the mouse models of OCT deficiency (OCTD) have been encouraging, but have also provided evidence that the immune system may be involved in mediating two limiting aspects of this technology, transient gene expression and inflammation. Although deletions in adenoviral early genes should limit adenoviral late gene expression and subsequent viral replication, there is in vitro and in vivo evidence of late gene expression after infection with adenoviruses deleted of some of the early genes. Future studies will focus on systematically defining the components of the virus that are recognized by the immune system and mutating these gene products. The development of an approach to gene therapy that safely, stably, and efficiently transduces gene expression holds the promise of revolutionizing the treatment of inborn errors of urea synthesis. © 1995 Wiley‐Liss, Inc.

Inborn errors of urea synthesis.

Inborn errors of urea synthesis can present in the newborn period as a catastrophic illness or later in childhood or adulthood with an indolent course punctuated by hyperammonemic episodes. Because symptoms mimic other neuropsychiatric disorders, it is common for there to be a delay in diagnosis, often with dire consequences. Diagnosis relies on the combination of clinical suspicion and the measurement of ammonium, lactate, and amino acids in plasma and organic acids and orotic acid in urine. Treatment involves nitrogen restriction combined with the stimulation of alternate pathways of waste nitrogen excretion. More recently liver transplantation has been performed as enzyme replacement therapy. The outcome is poor in children who survive prolonged neonatal hyperammonemic coma, with most manifesting developmental disabilities. The etiology of neuronal injury in this disorder is unclear but may involve some combination of ammonia/amino acid accumulation, neurotransmitter alterations, and excitotoxic injury. Gene therapy holds the promise of improved treatment in the future.

Quinolinate in brain and cerebrospinal fluid in rat models of congenital hyperammonemia.

Children with inborn errors of urea synthesis who survive neonatal hyperammonemic coma commonly exhibit cognitive deficits and neurologic abnormalities. Yet, there is evidence that ammonia is not the only neurotoxin. Hyperammonemia appears to induce a number of neurochemical alterations. In rodent models of hyperammonemia, uptake of L-tryptophan into brain is increased. It has been reported that in an experimental rat model of hepatic encephalopathy, in the ammonium acetate-injected rat, and in patients with hepatic failure and inborn errors of ammonia metabolism, quinolinate, a tryptophan metabolite, is increased. Elevations in quinolinate are of particular concern, as quinolinate could excessively activate the N-methyl-D-aspartate subclass of excitatory amino acid receptors, thereby causing selective neuronal necrosis. We sought to identify an animal model that would replicate the increases in quinolinate that have been associated with hyperammonemia in humans. Levels of quinolinate were measured in hyperammonemic urease-infused rats and ammonium acetate-injected rats. In the urease-infused rat, brain tryptophan was doubled, and serotonin and its metabolite 5-hydroxyindoleacetic acid were significantly increased. Yet, despite the increase in tryptophan and evidence for increased metabolism of tryptophan to serotonin, there were no observed increases of quinolinate in brain, cerebrospinal fluid, or plasma. In the ammonium acetate-injected rat, significant increases of 5-hydroxyindoleacetic acid in cerebral cortex were also observed, but quinolinate did not change in cerebrospinal fluid or cerebral cortex. In summary, we were unable to demonstrate an increase of quinolinate in brain or cerebrospinal fluid in these rat models of hyperammonemia.

Prospective treatment of urea cycle disorders

We present a diagnostic and therapeutic protocol designed to prevent clinical expression of inborn errors of urea synthesis in the neonatal period, and discuss the long-term developmental outcome of survivors. The families of 32 infants, among 43 identified prenatally as being at risk for a urea cycle disorder, chose to have their infants treated according to a diagnostic and therapeutic protocol, beginning at birth. The therapy was effective in avoiding neonatal hyperammonemic coma and death in seven patients with carbamoyl phosphate synthetase deficiency, argininosuccinate synthetase deficiency, and argininosuccinate lyase deficiency. When treated prospectively, five of eight patients with ornithine transcarbamylase deficiency avoided severe hyperammonemia and survived the neonatal period. Two patients with carbamoyl phosphate synthetase deficiency and two with ornithine transcarbamylase deficiency have subsequently died; three additional patients with the latter disorder have received orthotopic liver transplants. Our experience suggests that these surviving patients have had a more favorable neurologic outcome than patients rescued from neonatal hyperammonemic coma. However, all of them require a burdensome medical regimen and may have handicaps that include impairment of development and recurrent episodes of hyperammonemia. Further, those with deficiency of carbamoyl phosphate synthetase or ornithine transcarbamylase have a high mortality rate.

Dose-dependent pharmacokinetics of benzoic acid following oral administration of sodium benzoate to humans

Plasma concentration-time data for benzoic and hippuric acids and urinary excretion-time data for hippuric acid were analyzed simultaneously after oral doses of 40, 80 or 160 mg/kg sodium benzoate administered at least one week apart to 6 healthy subjects. The mean AUCs of benzoic acid after the doses of 80 and 160 mg/kg of sodium benzoate were 3.7- and 12.0-times greater, respectively, than after 40 mg/kg. However, the mean AUC of hippuric acid was roughly proportional to the benzoate doses. The observed data were explained by a one-compartment model with first-order rate absorption and Michaelis-Menten elimination of benzoic acid, together with a one-compartment model with first-order elimination for hippuric acid. Although the maximum rate of biotransformation of benzoic acid to hippuric acid varied between 17.2 and 28.8 mg.kg-1.h-1 among the six individuals, the mean value (23.0 mg.kg-1.h-1) was fairly close to that provided by daily maximum dose (0.5 g.kg-1.day-1) recommended in the treatment of hyperammonaemia in patients with inborn errors of ureagenesis. The individual maximum rate of metabolism can be estimated from the urinary excretion rate of hippuric acid 1.5 to 3 h after the single oral dose of 80 to 160 mg.kg-1 sodium benzoate. The justification of this concept requires further studies in patients with inborn errors of urea synthesis.

Phenylacetylglutamine May Replace Urea as a Vehicle for Waste Nitrogen Excretion

Phenylacetylglutamine (PAG), the amino acid acetylation product of phenylacetate (or phenylbutyrate after beta-oxidation) was evaluated as a waste nitrogen product in patients with inborn errors of urea synthesis. A boy with carbamyl phosphate synthetase deficiency receiving a low nitrogen intake excreted 80-90% of administered phenylacetate or phenylbutyrate as PAG. The amount of PAG nitrogen excreted varied from 38-44% of his dietary nitrogen, similar to the relationship between urea nitrogen and dietary nitrogen found in normal subjects receiving low dietary nitrogen. With few exceptions, neither phenylacetate nor phenylbutyrate accumulated in plasma. Treatment with relatively high dose phenylacetate or phenylbutyrate (0.5-0.6 g/kg/d) resulted in normal daytime levels of glutamine. These data suggest that PAG may replace urea as a waste nitrogen product when phenylbutyrate is administered at a dose that yields PAG nitrogen excretion equal to 40-44% of a low nitrogen intake.

Cognitive development in children with inborn errors of urea synthesis.

AbstractChildren with congenital urea cycle disorders are at a high risk for cerebral damage, mental retardation and other developmental disabilities. Intellectual outcome appears to be correlated with the severity of the underlying cerebral damage and the duration of hyperammonemic coma. Thus, if a good outcome is to Le possible, early diagnosis and treatment is essential. However, even prospective treatment of affected children may not prevent cognitive impairment and even asymptomatic hyperammonemia may have subtle effects on intellect.

Determination of benzoic acid and hippuric acid in human plasma and urine by high-performance liquid chromatography

For patients with inborn errors of urea synthesis, oral administration of sodium benzoate is the usual treatment to increase the nitrogen excretion. Thus, monitoring hippuric acid and benzoic acid simultaneously in human biological fluids is considered to be clinically important. We developed a simple and accurate high-performance liquid chromatographic method for the simultaneous determination of hippuric acid and benzoic acid in human plasma and urine. This method requires no extraction step. Aliquots of urine and plasma are added to a solution of internal standard ( o-chlorobenzoic acid) in acetonitrile and directly injected onto a reversed-phase column using an acidic (pH2.7) eluent and ultraviolet detection at 235 nm. The preliminary plasma concentration-time and urinary excretion rate-time profiles of hippuric acid and benzoic acid from a healthy subject receiving small, medium and large doses of sodium benzoate are reported.

Nonlinear elimination of benzoate in patients with congenital hyperammonemia

Sodium benzoate is effective for treatment of hyperammonemia caused by inborn errors of urea synthesis) -4 Although previous reports ~, 2 have suggested that relatively large doses of benzoate can be tolerated without toxicity, Sorrie adverse effects, 3,4 including death, were reported at higher doses. At present, however, there is little information concerning the blood elimination kinetics of benzoate. We studied the pharmacokinetics of benzoate in two patients with hyperammonemia.

Treatment of urea cycle disorders.

Recent advances in the treatment of inborn errors of urea synthesis have significantly decreased mortality. Treatment has included combining a high-quality low-protein diet with supplements of deficient metabolites and stimulation of alternate pathways of waste nitrogen excretion. Long-term alternate pathway therapy, using sodium benzoate and sodium phenylacetate, has generally been unassociated with signs of toxicity. However, acute intoxications have simulated hyperammonemic crises. Neurologic outcome appears to be primarily a function of duration of neonatal hyperammonemic coma, although ongoing accumulation of urea cycle intermediates may also play a role. Early recognition and treatment are critical if a good outcome is to be possible.

1193 THE UREASE INFUSED RAT AS A MODEL OF INBORN ERRORS OF UREA SYNTHESIS

Rats treated with intravenous urease become acutely hyper-ammonemic (HA) and have increased tryptophan transport into the brain associated with elevated levels of serotonin and 5-hydroxy indoleacetic acid (HIAA) [Life Sciences 33; 2417, 1983]. We have implanted intraperitoneally 7 and 14 day Alzet osmotic pumps delivering 2.5 U urease/100g/24hr. Mean plasma ammonium levels were (X ± SEM) 64 ± 4 uM baseline and 392 ± 30 uM during urease infusion (p <.01) in 23 rats. HA lasted a mean of 8 days. Plasma amino acids showed a specific elevation in glutamiue 698 ± 57 uM versus baseline 412 ± 19 uM (p <.01) with no alterations in branched chain amino acids or tyrosine levels as is seen in models of portal-systemic shunting. Sham operated animals showed no significant biochemical changes. In the cortex of HA animals, levels of serotonin and HIAA were increased but levels of norepinephrine, dopamine and homovanillic acid were not altered. Food intake decreased more in the HA rats than in those receiving sham surgery -6.9 ± 1.4 vs. -4.6 ± 0.9 g/d. Weight loss was also greater in the HA rats 19.8 ± 4.4 vs. 3.0 ± 1.3 g (p< .01). Thus behaviorally, the HA rats were anorectic, similar to children with inborn errors of urea synthesis, which suggests a relationship between altered serotonin metabolism and anorexia. The urease treated rat may prove useful in studying the neurochemical and behavioral abnormalities associated with inborn errors of urea synthesis and may permit the testing of new therapeutic approaches.

Arginine, an indispensable amino acid for patients with inborn errors of urea synthesis.

The role of arginine as an essential amino was evaluated in four children with one of the deficiencies of carbamyl phosphate synthetase, ornithine transcarbamylase, argininosuccinate synthetase, and argininosuccinase. Within 15-68 h after arginine deprivation nitrogen accumulated as ammonium or glutamine or both, but glutamine was quantitatively the largest nitrogen accumulation product. Concomitantly plasma and urinary urea levels decreased. Resumption of arginine intake (or citrulline in the case of ornithine transcarbamylase deficiency) promptly led to correction of the hyperammonemia, hyperglutaminemia and hypoargininemia. Ornithine was an unsatisfactory substitute for arginine. Arginine deprivation did not interfere with carbamyl phosphate synthesis as manifested by orotic aciduria. It is concluded that arginine is an indispensable amino acid for children with inborn errors of ureagenesis and its absence results in the rapid onset of symptomatic hyperammonemia.

Treatment of episodic hyperammonemia in children with inborn errors of urea synthesis.

Although normal plasma ammonium levels can be maintained in children with inborn errors of ureagenesis, these children are vulnerable to episodic hyperammonemia often resulting in coma and death. To treat such episodes, we designed a therapeutic protocol that included prompt recognition of hyperammonemia, therapy with intravenous sodium benzoate, sodium phenylacetate, and arginine, and nitrogen-free intravenous alimentation. Dialysis was performed if the hyperammonemia was unresponsive to drug therapy. Twelve episodes of hyperammonemia in seven children deficient in carbamyl phosphate synthetase, ornithine transcarbamylase, or argininosuccinic acid synthetase were treated; one patient died and the others recovered. In two patients measurement of the distribution of urinary nitrogen revealed that hippurate nitrogen and phenylacetylglutamine nitrogen together accounted for 60 per cent of "effective" urinary waste nitrogen. Successful therapy of episodic hyperammonemia plays an important part in the long-term management of disorders of the urea cycle.