carlo dionisi vici, convegno mitocon 2014
TRANSCRIPT
![Page 1: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/1.jpg)
1
Terapie personalizzate: i cocktails di farmaci e gli integratori
Mitocon 2014
Carlo Dionisi-Vici U.O.C. Patologia Metabolica
Dipartimento di Medicina Pediatrica
![Page 2: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/2.jpg)
a) Malattie che causano “intossicazione” (acuta & cronica) Aminoacidopatie - PKU, MSUD, tirosinemia, omocistinuria Acidemie Organiche (Propionica, Metilmalonica, Isovalerica, Glutarica) Difetti del Ciclo dell’Urea Intolleranza a zuccheri - Galattosemia, Intolleranza al Fruttosio Intosicazione da Metalli - rame, ferro Porfirie b) Malattie del Metabolismo Energetico Difetti ossidazione acidi grassi, difetti catena respiratoria, PC, PDH, Krebs Malattie citosoliche (glicolisi/gluconeogenesi/glicogeno, difetti metabolismo pentoso fosfati) c) Malattie da Carenza di Substrati Difetti metabolismo delle vitamine - B12, folati, B6, B1 & metalli – rame Difetti metabolismo creatina Difetti di sintesi dei neurotrasmettitori & aminoacidi - serina, glutammina Difetti di sintesi del colesterolo d) Disordini di Molecole Complesse Malattie lisosomiali Malttie perossisomiali Sindromi CDG Disturbi metabolismo fosfolipidi
Classificazione delle Malattie Metaboliche
![Page 3: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/3.jpg)
ac. grassi zuccheri proteine
FFA G6P
piruvato
glucosio
lattato acil-CoA
acil-carnitine PDH
ciclo Krebs
I II III IV V
catena respiratoria ATP
β-ossidazione
Acetil-CoA e-
CORPI CHETONICI
aminoacidi
ac.organici
ciclo urea
UREA
NH4+
IL METABOLISMO INTERMEDIO
![Page 4: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/4.jpg)
![Page 5: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/5.jpg)
Terapia delle Malattie Metaboliche
• Dietetica • Vitamine - cofattori • Farmaci • Terapia cellulare • Trapianto d’organo • Terapia enzimatica sostitutiva • Inibitori sintesi substrati tossici • Terapie chaperon • Terapia genica
nessuna terapia # 40-30% trattamenti di supporto – cure palliative
![Page 6: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/6.jpg)
Pronto Soccorso OBG 1987 > 3 anni LARINGITE ACUTA Eo: condizioni generali gravi, dispnea intensa, stridore inspiratorio, FR 56/min + ATASSIA
….in ANAMNESI…….. Abortività materna ripetuta Ricorrenti episodi di dispnea/tachipnea con STRIDORE LARINGEO @ 1 e 2 anni: DERMATITE SEBORROICA del capo seguita da ALOPECIA
Esami di laboratorio: lattato elevato pH 7.4 EB – 19 bicarbonati 6 mEq - pCO2 15.4 Anion Gap 25
Malattia Metabolica ???
Diagnosi?……..laringite???
SCARSISSIMA RISPOSTA ALLA TERAPIA STEROIDEA e O2
![Page 7: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/7.jpg)
![Page 8: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/8.jpg)
Dionisi-Vici C, Bachmann C, Graziani MC, Sabetta G. Laryngeal stridor as a leading symptom in a biotinidase-deficient patient. J Inherit Metab Dis. 1988;11(3):312-3.
Sospetto deficit BIOTINIDASI
BIOTINA 5 mg per os Dopo 2 ore COMPLETA NORMALIZZAZIONE DEL QUADRO RESPIRATORIO E DELLE ALTERAZIONI DI LABORATORIO
ELISA nel 2006 laurea in Economia
![Page 9: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/9.jpg)
Pt. 1 • 5 mesi diagnosi Leucemia Linfatica Acuta cellule B • Chemioterapia in accordo con INTERFANT 2006 • Diarrea e vomito dopo la prima somministrazione di Metotrexate (MTX) ad alto dosaggio dosaggio • Nutrizione parenterale totale (TPN) • giorno 19: 3 settimane di terapia MTX, deterioramento clinico, tachipnea, letargia • Grave acidosi metabolica + iperlattacidemia • Infusione di bicarbonati senza miglioramento > dialisi • Valutazione matabolica: Analisi degli acidi organici urinari
Pt. 2 • 9 anni diagnosi di Leucemia Mieloide Acuta. • Vomito persistente dopo chemioterapia • Nutrizione parenterale totale (TPN) • giorno 19 TPN: deterioramento clinico, tachipnea, rapido cambiamento dello stato mentale • Grave acidosi metabolica + iperlattacidemia • Infusione di bicarbonati senza miglioramento •Valutazione matabolica: Analisi degli acidi organici urinari
Maiorana 2014
![Page 10: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/10.jpg)
10.00 15.00 20.00 25.00 30.00 35.00
1000000
2000000
3000000
4000000
5000000
6000000
7000000
8000000
9000000
1e+07
1.1e+07
1.2e+07
1.3e+07
1.4e+07
1.5e+07
1.6e+07
1.7e+07
1.8e+07
1.9e+07
Time-->
1 2
3 4
5
6
7
8
is is 9
10
1) Lattato 2) 2-OH-butirrato 3) Piruvato 4) 2-OH-isovalerato 5) 2-cheto-butirrato 6) 2-cheto-isovalerato 7) 2-cheto-3-metil-valerico 8) 2-cheto-isocaproato 9) 2-cheto-glutarato 10) 2-cheto-adipato
Maiorana 2014
![Page 11: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/11.jpg)
Enzimi dipendenti dalla Tiamina
![Page 12: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/12.jpg)
L’effetto della Tiamina in caso di deficit secondario
Maiorana 2014
![Page 13: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/13.jpg)
Carrozzo 2014 submitted
Caso clinico Maschio, primogenito da genitori italiani consanguinei - Nella prima infanzia: ricorrenti episodi di sonnolenza e chetonuria
- All’età di 3 anni dolore muscolare e faticabilità
- All’età di 4,5 anni un episodio di letargia, ipotonia, sudorazione e pallore dopo 17 ore di digiuno. Citolisi epatica GOT/GPT 199/209, chetonuria, epatomegalia, iperecogenicità epatica → biopsia epatica → deficit di fosforilasi (glicogenosi VI) - A 15 anni progressivo sviluppo di intolleranza allo sforzo (test da sforzo interrotto dopo 1 minuto). ECG, ecocardiogramma, neurografia, elettromiografia nella norma
Parametri biochimici: aumento intermittente di lattato plasmatico + un caratteristico profilo di aumento degli AA ramificati e alloisoleucina (range 4-16µM/L) e presenza di α-chetoacidi urinari
![Page 14: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/14.jpg)
10.00 12.00 14.00 16.00 18.00 20.00 22.00 24.00 26.00 28.00 30.00
2000000
4000000
6000000
8000000
1e+07
1.2e+07
1.4e+07
Time >
4
pyruvic
2-OH-isovaleric
2-ketoisovaleric
2-keto3-CH3-valeric
2-ketoisocaproic
lactic
IS
2-ketoglutaric
IS
Carrozzo 2014 submitted
![Page 15: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/15.jpg)
43 215 245 387 50973 3181
I40LfsX4 G461E
Carrozzo 2014 submitted
![Page 16: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/16.jpg)
Muscle
DLD
VDAC
Ctrl Pt. 1st Pt. 2nd
Pre-Riboflavin On Riboflavin
On-R
1. Partial restoration of the DLD protein at SDS-page of 2nd muscle biopsy and disappearance of increased mitochondrial proliferation at histochemical reactions (COX, NADH).
2. Complete resolution of clinical symptoms and normalization of urinary organic acid profile
Pre-R
Pt. 2nd
Muscle biopsies
Carrozzo 2014 submitted
![Page 17: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/17.jpg)
cytosol
FFA fatty acyl-CoA
carnitine
fatty acid oxidation
acetyl-CoA
βOX- cycle e- transfer
fatty acylCoA
carnitine Carnitine cycle
ketones CO2+H2O ketogenesis
mito
![Page 18: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/18.jpg)
Deficit Primario di Carnitina
No terapia carnitina 3 g/die
Tein 1990; Lamhonwah 2002
![Page 19: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/19.jpg)
anamnesi negativa, a 2 anni episodio febbrile → trasferita dall’Ospedale di Avezzano al OBG per scompenso cardiaco in cardiomiopatia dilatativa glicemia 23 mg/dl ammonio 215 mcg/dl acido urico 14 mg/dl EB -14 HCO3 12 SGOT 950 SGPT 938 CPK 1036 chetoni urine assenti
Difetto della beta-ossidazione > VLCAD
Ipoglicemia - cardiomiopatia
![Page 20: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/20.jpg)
DIETOTERAPIA LIPIDI CARBOIDRATI (MAIZENA) PASTI FREQUENTI - ENTERALE OLIO MCT (solo dif. lunga catena) DIGIUNO - FEBBRE – VACCINAZIONI
PRINCIPI DI TRATTAMENTO
FARMACI CARNITINA RIBOFLAVINA
FASI ACUTE INFUSIONE GLUCOSATA
![Page 21: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/21.jpg)
CINZIA deficit di VLCAD
![Page 22: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/22.jpg)
carnitina
acil-carnitina acil-CoA
Le acilcarnitine: una finestra sul mitocondrio 16/37
![Page 23: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/23.jpg)
459.5
542.6
200 250 300 350 400 450 500 550 m/z, amu
50
100
150
200
250
300
350
400
450
500
550
600
650
Inte
nsity
, cps
CTD
MC
AD
SCAD
VLC
AD IV
A H
MG
GA1
- G
A2
MM
A - P
A
CAC
T
LCH
AD -
MTP
Screening acilcarnitine in MSMS
![Page 24: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/24.jpg)
Enhance electron transfer within the respiratory chain
• Riboflavin (FAD precursor) • Niacin (NADH precursor)
CoQ (Idebenon, EPI-743)
Vitamin E
![Page 25: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/25.jpg)
Coenzyme Q10 • Primary CoQ deficiencies (mutations in enzymes involved in CoQ synthesis)
• Secondary CoQ deficiencies (mutations in other genes)
![Page 26: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/26.jpg)
![Page 27: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/27.jpg)
![Page 28: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/28.jpg)
• Neonatal-onset • full-term babies • normal pregnancy • symptom-free period • feeding refusal • vomiting • abnormal posturing, • lethargy, seizures, coma • death within a few days if
not appropriately treated
• Late-onset • variable clinical picture • acute life-threatening
enchephalopathy • intermittent or chronic
symptoms (ataxia, abnormal behaviour, recurrent vomiting with or without ketoacidosis, failure to thrive, liver dysfunction,developmental delay..)
ORGANIC ACIDURIAS Classical forms > disorders that cause intoxication
High risk of “acute metabolic decompensation” triggered by stress events fever, infections, diarrhoea, fasting,immunisation, etc
![Page 29: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/29.jpg)
Organ complications
CNS Mental Retardation at long term follow-up (>2ys) ~ 70% of neonatal onset pts Basal ganglia stroke (MMA-PA)
MMAmut0
HEART Cardiomyopathy PA – MMA
KIDNEY Chronic renal failure MMA
PANCREAS Acute pancreatitis in PA
Propionic
![Page 30: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/30.jpg)
2-oxoisocaproic ac.
Isovaleryl-CoA
3-Methylcrotonyl-CoA
Acetyl-CoA
2-oxo-3methyl-valeric ac.
Tiglyl-CoA
Propionyl-CoA Methylmalonil-Co-A
Succinyl-Co-A
2-oxoisovaleric ac.
Methylacrylyl-CoA
Leucine
2-Methylbutyryl-CoA Isobutyryl-CoA
acetoacetate
Isoleucine Valine
3-Methylglutaconyl-CoA
3-OH-Methylglutaryl-CoA
2-methyl-3-OH butyryl-CoA
2-Methylacetoacetyl-CoA
3-OH-Isobutyryl-CoA
3-OH-Isobutyryc ac.
Methylmalonic semialdeide
methionine odd-chain fatty acids
cholesterol
B 12 biotin
biotin
thiamine
Vitamins in OAs
![Page 31: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/31.jpg)
PCC
carnitine
propionyl-carnitine
carnitine +
carnitine
CoA
Carnitine buffer function in OAs
![Page 32: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/32.jpg)
J Pediatr 1996
u. 5-oxoproline 156 2145 17
pl. GSH uM 0,3 0,005 0,1
![Page 33: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/33.jpg)
GSH:structure and function
NH3+
C
H2C
O-
O
H2C C
O
HHN C
CH2
O
SH
H
NH
CH2
C
O-
O
• GSH is the most abundant non-protein thiol in the cell • Functions: antioxidant, cytoprotection - critical in maintaining cell redox status • GSH is up-regulated during oxiative stress
![Page 34: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/34.jpg)
Oxidative stress
• Free radical generation is an essential contributor to health and homeostasis
• Free radicals (ROS & nitric oxide) play a vital role as mediators of , cell signalling, vascular tone, cell generation and degeneration, control of cellular homeostasis and defence against microorganisms • Free radical species are physiologically indispensable in maintaining redox homeostasis
severe disturbance in the prooxidants–antioxidants balance leading to cells and organs damage which activates/accelerate disease processes
Free radicals
Mild oxidation/physiology
Oxidative equilibrium
Free radicals
Severe oxidation/pathology
Oxidative stress
![Page 35: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/35.jpg)
• GSH (or reduced glutathione) is consumed in many enzymatic and non-enzymatic reactions, where it serves as a source of reducing equivalents
• GSH is used by glutathione peroxidases and can exchange with disulfides to yield GSSG
• GSSG (oxidized glutathione) via the action of glutathione reductase regenerates GSH at the expense of NADPH
• The glutathione S-transferases (GST) • plays a protective role generating GS-Pro from GSSG
GSH: uses, loss and replacement
![Page 36: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/36.jpg)
![Page 37: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/37.jpg)
EPI-743 is a therapeutic small-molecule designed to replete reduced glutathione through NQO1-catalyzed electron transfer from NADPH
EPI-743 is orally bioavailable and readily crosses the BBB
Shrader, W.D. et al 2011
α-tocotrienol quinone
EPI-743 restores glutathione cycle and lowers oxidative stress
![Page 38: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/38.jpg)
Pastore MGM 2013
EPI743: a treatment for SUCLA2 (& Leigh syndrome)?
![Page 39: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/39.jpg)
Newcastle Pediatric Mitochondrial Disease Scale
GMF PedQL MDCRS Improvement 10.0±11.1 p 0.006 Improvement 15.0±20.8 p 0.02
Martinelli et al. MGM 2012
EPI743: a treatment for SUCLA2 (& Leigh syndrome)?
![Page 40: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/40.jpg)
•The apparent safety of most agents has motivated a continued prescriptions • Patients and physicians shoul no longer rely on potentially biased data, with the assiciated costs & risks
• Recommendations for treatment trials in mitochondrial diseases
Nat Rev Neurol 2013
35 studies selected from 1039 publications
The need of an EBM based approach
EPI743
![Page 41: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/41.jpg)
Cobalamin
Rutsch 2009
Inherited cobalamin defects
![Page 42: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/42.jpg)
Fischer et al.
![Page 43: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/43.jpg)
Pastore et al.
GSH in lymphocytes from 18 cblC patients
![Page 44: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/44.jpg)
C. Dionisi-Vici PI
Retinopathy – optic atrophy - nistagmous
![Page 45: Carlo Dionisi Vici, Convegno Mitocon 2014](https://reader030.vdocuments.pub/reader030/viewer/2022020122/556250b5d8b42a1b4b8b4cd7/html5/thumbnails/45.jpg)
OX/TOT ratio in IEM
0 0,2 0,4 0,6 0,8 1 1,2
CTRLS
NPC-Untreated
NPC-Treated
GAUCHER
GM1
Menkes
Wilson
SO
CBS
MTHFR
CBLC
HHH
OTC
ASL
ASS
VLCAD
MTP
MCAD
CACT
CPT1
PA
MMA
HMG
IVA
MITO
P = significant