Pathogenesis Of Phenylketonuria Research Articles

Oxidative stress in phenylketonuria—evidence from human studies and animal models, and possible implications for redox signaling

Phenylketonuria (PKU) is one of the commonest inborn error of amino acid metabolism. Before mass neonatal screening was possible, and the success of introducing diet therapy right after birth, the typical clinical finds in patients ranged from intellectual disability, epilepsy, motor deficits to behavioral disturbances and other neurological and psychiatric symptoms. Since early diagnosis and treatment became widespread, usually only those patients who do not strictly follow the diet present psychiatric, less severe symptoms such as anxiety, depression, sleep pattern disturbance, and concentration and memory problems. Despite the success of low protein intake in preventing otherwise severe outcomes, PKU's underlying neuropathophysiology remains to be better elucidated. Oxidative stress has gained acceptance as a disturbance implicated in the pathogenesis of PKU. The conception of oxidative stress has evolved to comprehend how it could interfere and ultimately modulate metabolic pathways regulating cell function. We summarize the evidence of oxidative damage, as well as compromised antioxidant defenses, from patients, animal models of PKU, and in vitro experiments, discussing the possible clinical significance of these findings. There are many studies on oxidative stress and PKU, but only a few went further than showing macromolecular damage and disturbance of antioxidant defenses. In this review, we argue that these few studies may point that oxidative stress may also disturb redox signaling in PKU, an aspect few authors have explored so far. The reported effect of phenylalanine on the expression or activity of enzymes participating in metabolic pathways known to be responsive to redox signaling might be mediated through oxidative stress.

Newly validated biomarkers of brain damage may shed light into the role of oxidative stress in the pathophysiology of neurocognitive impairment in dietary restricted phenylketonuria patients.

Despite a strict dietary control, patient with hyperphenylalaninemia or phenylketonuria may show cognitive and/or behavioral disorders. These comorbid deficits are of great concern to patients, families, and health organizations. However, biomarkers capable of detecting initial stages of neurological damage are not commonly employed. The pathogenesis of phenylketonuria is complex in nature. Increasingly, the role of oxidative stress has gained acceptance and biomarkers reflecting oxidative damage to the brain and easily accessible in peripheral biofluids have been validated using mass spectrometry techniques. In the present review, the role of oxidative stress in the pathogenesis of phenylketonuria and hyperphenylalaninemia has been updated. Moreover, we report on newly validated brain-specific lipid peroxidation biomarkers and inform on their relevance in the detection and monitoring of neurological damage in phenylketonuric patients. In preliminary studies, a correlation between lipid peroxidation biomarkers and neurological dysfunction in patients with PKU was reported. However, there is a need of adequately powered trials to confirm the validity of these biomarkers for early detection of brain damage, initiation of treatment, and reliably monitor evolving disease both in phenylketonuria and hyperphenylalaninemia.

Effect of Blood Phenylalanine Levels on Oxidative Stress in Classical Phenylketonuric Patients.

Mental retardation, which occurs in phenylketonuric patients, is associated with increased levels of phenylalanine, increased oxidative stress, and an imbalance of amino acids in the brain. Recent studies have shown that oxidative stress plays a role in the pathogenesis of phenylketonuria. In this work, we aimed to compare the influence of blood phenylalanine levels on oxidative stress parameters in phenylketonuric patients who divided patients into groups according to blood Phe levels during follow-up visits and compared these groups with healthy controls. Results showed significant differences in glutathione peroxidase (GSHPx), coenzyme Q10 (Q10), Q10/cholesterol, and L-carnitine levels in phenylketonuria patients and the control group. GSHPx, Q10, and Q10/cholesterol levels were significantly lower in poor adherence patients than in the control groups. L-carnitine levels were significantly increased in good adherence patients than poor adherence patients and decreased in poor adherence patients than healthy controls. No correlations were observed between phenylalanine and L-carnitine concentrations in poor adherence group. No significant differences were observed in paraoxonase 1(PON1), total antioxidant status(TAS), total oxidant status(TOS) and oxidative stress index(OSI) levels. As a result, in this work, poor adherence patients are prone to oxidative stress. Although the patients may have the same diagnosis, patients have different clinical characteristics and different prognosis. Antioxidants can be used as an adjuvant therapy in order to avoid neurological damage in these patients.

Serum ischemia modified albumin is a possible new marker of oxidative stress in phenylketonuria.

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.

Pathogenesis of cognitive dysfunction in phenylketonuria: Review of hypotheses

In untreated phenylketonuria (PKU), deficiency of phenylalanine hydroxylase (PAH) results in elevated blood phenylalanine (Phe) concentrations and severe mental retardation. Current dietary treatment prevents mental retardation, but cognitive outcome remains suboptimal. The mechanisms by which elevated blood Phe concentrations disturb cerebral metabolism and cognitive function have not been fully elucidated. In this review, we discuss different hypotheses on the pathogenesis of PKU, focusing on the effects of disturbed large neutral amino acid (LNAA) transport from blood to brain on cerebral neurotransmitter and protein synthesis. Although the definitive roles of these processes in PKU pathogenesis are not fully understood yet, both substantially influence clinical outcome.

Future treatment strategies in phenylketonuria

Phenylketonuria (PKU) was the first inherited metabolic disease in which treatment was found to prevent clinical features of the disorder; dietary management was established almost 60 years ago. The institution of a low-phenylalanine (Phe) diet in the first few weeks of life was made possible by Guthrie neonatal screening, which further increased effectiveness of therapy. Indeed, neonatal diagnosis of PKU followed by institution of a low-Phe diet has been a remarkable success in preventing the devastating brain damage associated with untreated PKU. Nevertheless, significant difficulties exist in caring for PKU patients, including problems with adhering to the prescribed dietary regimen and the presence of neurocognitive deficits despite therapy. During the past few years, several ideas for new treatment strategies have emerged. This review aims to address these treatment strategies based on theoretical considerations of the biochemistry and pathogenesis of PKU. Recent times have seen the introduction of a wide array of novel treatments currently in clinical use, including more palatable medical foods, glycomacropeptide, large neutral amino acids, and tetrahydrobiopterin. Human trials are underway using an enzymatic therapeutic approach, while preclinical work continues in the fields of gene and cellular therapy. These therapeutic strategies propose to treat PKU at various levels, including nutritional intake, gut, liver, and blood–brain barrier, and have the potential to further improve outcome in PKU.

Altered brain gene expression profiles associated with the pathogenesis of phenylketonuria in a mouse model

Background Phenylketonuria (PKU) is an autosomal recessive disorder caused by a deficiency of phenylalanine hydroxylase (PAH), which catalyzes the conversion of phenylalanine to tyrosine. The resultant hyperphenylalaninemia causes mental retardation, seizure, and abnormalities in behavior and movement. Methods We analyzed gene expression profiles in brain tissues of Pah enu2 mice to elucidate the mechanisms involved in phenylalanine-induced neurological damage. The altered gene expression was confirmed by real-time PCR and Western blotting. To identify markers associated with neurological damage, we examined TTR expression in serum by Western blotting. Results Gene expression profiling of brain tissue from a mouse model of PKU revealed overexpression of transthyretin ( Ttr), sclerostin domain containing 1 ( Sostdc1), α-Klotho ( Kl), prolactin receptor ( Prlr), and early growth response 2 ( Egr2). In contrast to its overexpression in the brain, TTR expression was low in the sera of PKU mice offered unrestricted access to a diet containing phenylalanine. Expression of TTR decreased in a time-dependent manner in phenylalanine-treated HepG2 cells. Conclusions These findings indicate that Ttr, Sostdc1, Kl, Prlr, and Egr2 can be involved in the pathogenesis of PKU and that phenylalanine might have a direct effect on the level of TTR in serum.

Phenylalanine can be detected in brain tissue of healthy subjects by 1H magnetic resonance spectroscopy

Transport of phenylalanine (Phe) and the other large neutral amino acids across the blood-brain barrier plays a crucial role in the pathogenesis of phenylketonuria (PKU). Thus, investigation of Phe transport kinetics by means of proton magnetic resonance spectroscopy (1H MRS) became an important research area in the mid 1990s. As 1H MRS measurements of brain phenylalanine are restricted to tissue concentrations above 100-150 micromol/kg wet weight, this approach was possible only in PKU patients, and comparison with healthy controls was not achieved. Using standardized single-dose oral Phe loading in three healthy subjects, it was shown that Phe values increase steeply, peak at about 1 h post load, and decrease thereafter. In a single case study, repetitive Phe loading was then performed to achieve a plateau of high blood Phe concentrations for several hours. It was demonstrated that detection and monitoring of brain Phe concentrations is feasible by means of 1H MRS. This approach constitutes a prerequisite for describing carrier kinetics in health.

Phenylketonuria: Tyrosine beyond the phenylalanine‐restricted diet

Controversies exist on the role of tyrosine in the pathogenesis of phenylketonuria (PKU) and, consequently, on the therapeutic role of tyrosine. This review examines data and theoretical considerations on the role of tyrosine in the pathogenesis and treatment of PKU. It is concluded that treatment with tyrosine alone to replace the phenylalanine-restricted diet cannot be justified. A treatment with large neutral amino acids (LNAA) including tyrosine to restore the balance in the transport of phenylalanine and other LNAA across the blood-brain barrier deserves further investigation. Such studies should prove the safety and the efficacy of such a treatment, finding the optimal dose of all LNAA, disclosing the correct age to start and the way to monitor treatment biochemically.

95 EVALUATION OF PLASMA PHENYLLACTATE IN PHENYLKETONURIA

There is a controversy whether, in addition to phenylalanine (PHE), products of PHE transamination are involved in the pathogenesis of phenylketonuria (PKU). We determined phenyllactate in plasma by HPLC and PHE by amino acid analysis monthly for half a year in 24 adult patients with classic PKU who had stopped diet. Phenyllactate was measurable in all plasma samples (mean: 52 μmol/l; range: 7-154; mean PHE: 1250 μmol/l; range: 670 - 1990) Phenyllactate and PHE were linearly correlated (r = 0.734 [n = 144] p<0.0001). The correlation was stronger for the PHE level from the same date than for the previous PHE level (r = 0.734 versus 0.646). This disproves the hypothesis that phenyllactate is a useful parameter of long-term dietary control in PKU. There was a positive correlation between phenyllactate, but not PHE, and quality of dietary control during the first 12 years of age aa judged by median values of all quantitative PHE determinations over 24 6-months periods (p<0.05). We find it difficult to interpret this observation. Patients with higher plasma phenyllactate at a given PHE also tended to have lower IQ values, although this correlation did not reach significance. From our data regular monitoring ot plasma phenyllactate is not indicated in patients with PKU. However, the extent of PHE transamination could be are independent parameter influencing the quality of dietary control. Further correlative studies of mental and biochemical phenotype in PKU patients are indicated and may help to facilitate individual decisions on the necessity and quality of life-long dietary therapy.

A synopsis of the unconjugated acidic transamination metabolites of phenylalanine in phenylketonuria.

We present blood and urine levels of unconjugated o-hydroxyphenylacetic, phenyllactic and phenylpyruvic acids in 61 children (2 years of age and above) and juveniles with phenylketonuria on or partially off diet. The samples were obtained during 185 scheduled outpatient visits and have been analysed with gas chromatographic methods. The compiled data define reference ranges of phenylalanine transamination capacity and of renal transport of metabolites which may be of value in further studies on the pathogenesis of phenylketonuria.

Birth Weight and Pathogenesis in Phenylketonuria

The birthweights of an ethnically homogeneous sample of infants with phenylketonuria, their unaffected siblings, and control infants were compared after adjusting for the effects of: mother's age, mother's date of birth, mother's height and obstetric history, the length of gestation, the infant's sex, the place and date of birth. There were no significant differences between the infants with phenylketonuria and their unaffected siblings either in adjusted or unadjusted birthweights. Control infants had slightly, but statistically significant, greater adjusted and unadjusted birthweights than the combined phenylketonuria and unaffected sibling groups. This effect of the phenylketonuria gene is a previously unreported finding but unlikely to be related to the pathogenesis of phenylketonuria. Our results do not provide support for the "justification" hypothesis that the mental and neurological defects in phenylketonuria result from prenatal tyrosine deprivation which would be reflected in lower birthweights.

The metabolism of l- m-tyrosine: the use of a putative precursor to investigate the increased production of m-hydroxymandelic acid in phenylketonuria

Several urinary meta-substituted phenols appear to be of endogenous origin. However, the production of these compounds is reduced in phenylketonuria with the exception of m-hydroxymandelic acid whose excretion is approximately doubled. This phenomenon has been investigated in two patients with phenylketonuria using the putative precursor l- m-tyrosine labelled with deuterium. Metabolism of this compound in these patients was comparable to that in healthy adults although much less was converted to m-hydroxymandelic acid and the excretion pattern of this metabolite was different. This apparent anomaly is attributed to smaller metabolic compartments in phenylketonuria and a lower threshold for the metabolism of m-tyramine via β-hydroxylation. Incorporation into the natural pathway was shown by depletion of endogenous m-hydroxymandelic acid. The results are further support for the ideas that the amine precursors of m-hydroxymandelic acid, m-tyramine and m-octopamine, have a functional role and may be important in the pathogenesis of phenylketonuria.

Inhibition by L-phenylalanine of tyrosine transport by synaptosomal plasma membrane vesicles: implications in the pathogenesis of phenylketonuria.

The effect of L-phenylalanine on the transport of tyrosine was studied using membrane vesicles from rat brain synaptosomes. Phenylalanine, which is accumulated in phenylketonuria, competitively inhibits tyrosine uptake at concentrations similar to those found in phenylketonuric patients, with a Ki of the same order of the Km for tyrosine. This inhibition could be responsible for the depletion of catecholamines observed in phenylketonuria.

Inhibition by L-phenylalanine of tryptophan transport by synaptosomal plasma membrane vesicles: implications in the pathogenesis of phenylketonuria.

Phenylalanine is accumulated in the genetically linked deficiency phenylketonuria. The effect of L-phenylalanine on the transport of tryptophan was studied using membrane vesicles from rat-brain synaptosomes. Phenylalanine at similar concentrations to those found in phenylketonuric patients competitively inhibits tryptophan uptake, with a Ki of the same order as the Km for tryptophan. This inhibition could be responsible for the depletion of serotonin found in phenylketonuria.

The electro-encephalogram in phenylketonuria

SynopsisElectro-encephalographic findings in 24 patients suffering from phenylketonuria are described.Six of these had normal electro-encephalograms.In the remaining 18 almost the whole gamut of known E.E.G. abnormalities was found. No correlations were found between the E.E.G. findings and the clinical and biochemical features.The maturational development of the E.E.G. dominant rhythms and abnormalities are described and discussed in this untreated series. Comparison is made with series treated with a low phenylalanine diet reported in the literature.The aetiology of the E.E.G. abnormalities is discussed. The E.E.G. studies most likely to illuminate the pathogenesis of phenylketonuria are postulated.It is concluded that to date there is no E.E.G. pattern, either in single or serial records, which is pathognomonic of phenylketonuria.