Phenylketonuria

Definition:

Phenylketonuria (commonly known as PKU) is an inherited disorder that

increases the levels of a substance called phenylalanine in the blood.
Phenylalanine is a building block of proteins (an amino acid) that is obtained
through the diet. It is found in all proteins and in some artificial sweeteners. If
PKU is not treated, phenylalanine can build up to harmful levels in the body,
causing intellectual disability and other serious health problems.

The signs and symptoms of PKU vary from mild to severe. The most severe form
of this disorder is known as classic PKU. Infants with classic PKU appear normal
until they are a few months old. Without treatment, these children develop
permanent intellectual disability. Seizures, delayed development, behavioral
problems, and psychiatric disorders are also common. Untreated individuals may
have a musty or mouse-like odor as a side effect of excess phenylalanine in the
body. Children with classic PKU tend to have lighter skin and hair than
unaffected family members and are also likely to have skin disorders such as
eczema.

Less severe forms of this condition, sometimes called variant PKU and non-PKU
hyperphenylalaninemia, have a smaller risk of brain damage. People with very
mild cases may not require treatment with a low-phenylalanine diet.

Babies born to mothers with PKU and uncontrolled phenylalanine levels (women
who no longer follow a low-phenylalanine diet) have a significant risk of
intellectual disability because they are exposed to very high levels of
phenylalanine before birth. These infants may also have a low birth weight and
grow more slowly than other children. Other characteristic medical problems
include heart defects or other heart problems, an abnormally small head size
(microcephaly), and behavioral problems. Women with PKU and uncontrolled
phenylalanine levels also have an increased risk of pregnancy loss.

Metabolic pathway:

PAH is an integral enzyme used to convert the amino acid Phenylalanine to the
amino acid Tyrosine. Tyrosine is then subsequently catalyzed using another
enzyme, Tyrosine hydroxylase (TH). TH functions in conjunction with
tetrahydrobiopterin (BH4), the same cofactor used with PAH, to produce L-3,4-
dihydroxyphenylalanine, more commonly referred to as L-DOPA.
Pathophysiology:

The enzyme phenylalanine hydroxylase normally converts the amino acid

phenylalanine into the amino acid tyrosine. If this reaction does not take place,
phenylalanine accumulates and tyrosine is deficient. Excessive phenylalanine
can be metabolized into phenylketones through the minor route, a transaminase
pathway with glutamate. Metabolites include phenylacetate, phenylpyruvate and
phenethylamine. Elevated levels of phenylalanine in the blood and detection of
phenylketones in the urine is diagnostic, however most patients are diagnosed
via newborn screening.

Phenylalanine is a large, neutral amino acid (LNAA). LNAAs compete for

transport across the blood–brain barrier (BBB) via the large neutral amino acid
transporter (LNAAT). If phenylalanine is in excess in the blood, it will saturate the
transporter. Excessive levels of phenylalanine tend to decrease the levels of
other LNAAs in the brain. However, as these amino acids are necessary for
protein and neurotransmitter synthesis, Phe buildup hinders the development of
the brain, causing intellectual disability.
Etiology/ Causes:

Genetics:

This condition is inherited in an autosomal recessive pattern, which means both

copies of the gene in each cell have mutations. The parents of an individual with
an autosomal recessive condition each carry one copy of the mutated gene, but
they typically do not show signs and symptoms of the condition.

Manifestations:

Most individuals with phenylketonuria (PKU) appear normal at birth. If newborn

screening fails, progressive developmental delay is the most common
presentation. Other findings in untreated children in later infancy and childhood
may include vomiting, mousy odor, eczema, seizures, self-mutilation, and severe
behavioral disorders.

Older individuals who cease dietary treatment in childhood may have evidence of
demyelination on MRI. Occasionally, deterioration of cognitive performance or
motor skills also may be present. Intelligence quotients (IQs) may drop by 10
points or more if the diet is stopped in midchildhood.

Diagnostic Procedures:

Screening and presentation

PKU is commonly included in the newborn screening panel of most countries,
with varied detection techniques. Most babies in developed countries are
screened for PKU soon after birth.[10] Screening for PKU is done with bacterial
inhibition assay (Guthrie test), immunoassays using fluorometric or photometric
detection, or amino acid measurement using tandem mass spectrometry
(MS/MS). Measurements done using MS/MS determine the concentration of Phe
and the ratio of Phe to tyrosine, both of which will be elevated in PKU.

If a child is not screened during the routine newborn screening test (typically
performed 2 – 7 days after birth, using samples drawn by neonatal heel prick),
the disease may present clinically with seizures, albinism (excessively fair hair
and skin), and a "musty odor" to the baby's sweat and urine (due to
phenylacetate, one of the ketones produced). In most cases, a repeat test should
be done at approximately two weeks of age to verify the initial test and uncover
any phenylketonuria that was initially missed.
Untreated children are normal at birth, but fail to attain early developmental
milestones, develop microcephaly, and demonstrate progressive impairment of
cerebral function. Hyperactivity, EEG abnormalities, and seizures, and severe
learning disabilities are major clinical problems later in life. A "musty or mousy"
odor of skin, hair, sweat and urine (due to phenylacetate accumulation), as well
as a tendency towards hypopigmentation and eczema, are also observed.
In contrast, affected children who are detected and treated are less likely to
develop neurological problems or have seizures and intellectual disability, though
such clinical disorders are still possible.

Management/ Treatment:

The classic treatment of phenylketonuria is dietary restriction of phenylalanine to

a degree that maintains plasma phenylalanine concentrations less than 360
µmol/L yet provides for normal growth. This requires a very restrictive diet and
can only be accomplished with the use of a synthetic phenylalanine-deficient
formula. Breastfeeding in infancy is possible, but must be limited to a degree.
Plasma phenylalanine concentrations must be closely monitored. Older versions
of synthetic formulas are often poorly tolerated because of taste. However, many
new products provide phenylalanine-free protein with an improved taste. The
majority of phenylalanine-deficient formulas and food are supplemented with free
amino acids; these are often bitter tasting and may be metabolized less efficiently
than whole proteins. Glycomacropeptide (GMP) is an abundant, naturally
occurring protein in whey that lacks phenylalanine in its primary amino acid
sequence; foodstuffs made with GMP are more palatable than traditional
phenylalanine-free foods (Lim et al 2007) and their use may be associated with
improved bone health and metabolic stress, at least in a murine model of
phenylketonuria, in comparison to a diet based upon free amino acids (Solverson
et al 2012a; 2012b).
Exciting new therapies have the potential to significantly improve the lives of
individuals with phenylketonuria (Santos et al 2006). It has long been known that
tetrahydrobiopterin is a cofactor for phenylalanine hydroxylase, the enzyme that
is deficient in phenylketonuria (Thöny et al 2000). Even though individuals with
phenylalanine hydroxylase deficiency have normal tetrahydrobiopterin
metabolism, a subset of phenylalanine hydroxylase-deficient patients will
respond to tetrahydrobiopterin supplementation by lowering their plasma
phenylalanine concentrations (Kure et al 1999). This topic has been extensively
reviewed (Harding 2010). Tetrahydrobiopterin supplementation may lead to a
significant increase in dietary protein tolerance and consequently less onerous
dietary restriction (Hennermann et al 2005). The effect of tetrahydrobiopterin
supplementation upon phenylalanine hydroxylase function is multifactorial (Blau
and Erlandsen 2004). Sapropterin dihydrochloride (Kuvan™ by BioMarin of
Novato, California), a synthetic form of tetrahydrobiopterin, has been extensively
studied in clinical trials for this purpose and is now approved for clinical use in the
US, Canada, Japan, and the European Union. Plasma phenylalanine
concentrations decrease to below 600 µmol/L without dietary protein restriction in
approximately 10% of adults taking sapropterin (10 mg/kg per day) (Burton et al
2007). The percentage of “‘sapropterin-responsive”’ individuals may approach
20% if a higher dose, 20 mg/kg per day, is administered. Long-term efficacy of
sapropterin therapy has been demonstrated in randomized, placebo-controlled,
crossover trials in adults (Levy et al 2007) and children (Trefz et al 2009) with
phenylketonuria. In the latter trial, plasma phenylalanine concentrations
decreased by at least 30% in approximately half of children with phenylketonuria
although most still required some degree of dietary protein restriction and
continued use of phenylalanine-free medical foods. Individuals with ‘milder’
degrees of phenylketonuria who naturally tolerate somewhat greater amounts of
dietary protein are more likely to respond to sapropterin treatment, but
surprisingly even a few individuals with very severe phenylketonuria exhibit lower
plasma phenylalanine concentrations while on sapropterin therapy.
Unfortunately, the phenylalanine hydroxylase genotype of the individual patient
does not predict sapropterin responsiveness (Levy et al 2007), and subjects’
response to sapropterin treatment can only be adequately assessed by
measuring plasma phenylalanine concentrations repeatedly during a trial of daily
sapropterin therapy lasting at least 4 weeks. Sapropterin is also approved for use
during pregnancy in women who are responsive, but experience with this is still
limited (Koch 2008).

Another therapeutic approach is to orally supply all of the large neutral amino
acids, except phenylalanine, in order to compete with phenylalanine for transport
into the brain, which is mediated by the neutral amino acid carrier at the blood-
brain barrier. This therapy lowers brain phenylalanine concentrations and leads
to improvements in EEG patterns of adults with hyperphenylalaninemia (Pietz et
al 1999). With the addition of arginine and lysine to the neutral amino acid mix,
some competition with phenylalanine uptake in the intestinal lumen may also be
achieved resulting in decreased plasma phenylalanine concentrations (Matalon
et al 2006). This therapy is not sufficiently robust to be routinely used in young
children or women during pregnancy, but can be successfully employed to block
the central nervous system effects of hyperphenylalaninemia in adolescents and
adults who are unable to adhere to the protein-restricted diet.

A potential treatment that should be effective in all individuals with

phenylketonuria is enzyme replacement or substitution therapy. Because
phenylalanine hydroxylase requires tetrahydrobiopterin cofactor to maintain its
correct physical structure and requires targeting to the liver, enzyme replacement
therapy with exogenously synthesized phenylalanine hydroxylase protein is
technically challenging. However, enzyme substitution therapy using the enzyme
phenylalanine ammonia lyase is a novel therapeutic approach (Sarkissian et al
1999) that is currently in clinical trial. Phenylalanine ammonia lyase is an enzyme
expressed in various plants, yeast, and bacteria that catalyzes the conversion of
phenylalanine to trans-cinnamic acid and ammonia. Phenylalanine ammonia
lyase is a monomer and requires no exogenous cofactors for catalytic activity.
Following the conjugation of polyethylene glycol to certain amino acid residues
on the surface of the protein to help protect phenylalanine ammonia lyase from
immunological destruction, phenylalanine ammonia lyase-polyethylene glycol is
administered by subcutaneous injection to individuals with phenylketonuria and
ultimately enters the blood to metabolize circulating phenylalanine (Sarkissian et
al 2008). The minor amount of trans-cinnamic acid produced is readily excreted
in urine and the ammonia is metabolized through the urea cycle. An open-label,
phase 2 clinical trial of phenylalanine ammonia lyase-polyethylene glycol
administered by subcutaneous injection to adults with phenylketonuria has been
completed and planning of a phase 3, randomized, blinded, placebo-controlled
trial is underway.

Therapy for all of the disorders with elevated phenylalanine concentrations

requires a specialized clinic setting with dieticians, social services, psychologists,
and metabolic specialists. The management team must be aware of the need for
education of individuals with phenylketonuria and their families, of the
psychological impact of a chronic disease, and of the financial constraints of
expensive, but essential, treatments that may not be fully covered by health
insurance.

There is some discussion about which individuals will tolerate relaxation of the
diet as adults. Possible predictors include brain phenylalanine concentrations or
genotype predictors of residual enzyme activity (Greeves et al 2000). Current
recommendations are that therapy should be for life to prevent declining
intellectual performance. However, unlike individuals with other inborn errors of
protein metabolism, patients with phenylketonuria do not feel ill when they ingest
excessive protein. The effects are subtle, but certainly can affect quality of life
just as severely as in other inborn errors of protein metabolism. These issues
must be addressed during adolescence, yet the typical adolescent must be
allowed some personal control over the treatment of their disease. It can be a
delicate balance.