The Metabolic &
`Molecular Bases of
`Inherited Disease
`
`eighth edition
`
`EDITORS
`
`ASSOCIATE EDITORS
`
`Charles R. Scriver, M.D.C.M.
`Arthur L. Beaudet, M.D.
`William S. Sly, MD.
`David Valle, M.D.
`
`A
`
`Barton Childs, M.D.
`Kenneth‘ W. Kinzler, Ph.D.
`Bert Vogelstein, M.D.
`
`lVlCCiRAW—HlLL
`
`Medical Publishing Division
`New York St. Louis
`San Francisco Auckland Bogota Caracas Lisbon London Madrid Mexico City
`Milan Montreal New Delhi San Juan Singapore Sydney Tokyo Toronto
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`McGraw-Hill
`A Division of The McGraw»H1‘ll Companies
`
`22
`
`The Metabolic and Molecular Bases of Inherited Disease, 8th Edition
`
`Copyright © 2001, 1995, 1989, 1983, 1978, 1972, 1966, 1960 by The McGraw—Hill Companies, Inc. Formerly published as
`The Metabolic Basis of Inherited Disease. All rights reserved. Printed in the United States of America. Except as
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`Library of Congress Cataloging-in-Publication Data
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`The metabolic and molecular bases of inherited disease / editors,
`Charles R. Scriver .
`.
`. [et al.].—8th ed.
`p.;
`cm.
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`Includes bibliographical references and index.
`ISBN 0-07-913035~6 (set)
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`1
`
`1. Metabolism, Inborn errors of
`Scriver, Charles R.
`
`2. Medical genetics.
`
`3. Pathology, Molecular. I.
`
`[DNLM: 1. Hereditary Diseases. 2. Metabolic Diseases. 3. Metabolism, Inborn Errors.
`WD 200 M5865 2001]
`RC627.8 . M47 2001
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`This material may be protected by Copyright law (Title 17 U.S. Code)
`
`c HA P T ER
`
`Lysinuric Protein
`Intolerance and Other
`
`Cationic Arninoacidurias
`
`Olli Simell
`
`lysine,
`. Membrane transport of cationic amino acids
`arginine, and ornithine is abnormal in four disease entities:
`classic cystinuria; lysinuric protein intolerance (hyperdi-
`basic aminoaciduria type 2, or familial protein intolerance);
`hyperdibasic aminoaciduria type 1; and isolated lysinuria
`(lysine malabsorption syndrome). Cystinuria,
`the most
`common of these, is dealt with in Chap. 191. About 100
`patients with lysinuric protein intolerance (LPI) have been
`reported or are known to me. Almost half of them are from
`Finland, where the prevalence of this autosomal recessive
`disease is 1 in 60,000. Autosomal dominant hyperdibasic
`aminoaciduria type 1 has been described in 13 of 33
`members in a French Canadian pedigree, and isolated
`lysinuria has been described in one Japa‘nese patient.
`Arginine and ornithine are intermediates in the urea
`cycle; lysine is an essential amino acid. In lysinuric protein
`intolerance (LPI) (MIM 222700), urinary excretion and
`clearance of all cationic amino acids, especially of lysine, are
`increased, and these amino acids are poorly absorbed from
`the intestine. Their plasma concentrations are low, and
`their body pools become depleted. The patie11ts have
`periods of hyperammonemia caused by “fuhctional”
`deficiency of ornithine, which provides the carbon skeleton
`of the urea cycle. Consequently, nausea and vomiting occur,
`and aversion to protein-rich food develops. The patients fail
`to thrive, and symptoms of protein malnutrition are further
`aggravated by lysine deficiency.
`. Patients with LPI are usually symptom-free when breast-
`fed but have vomiting and diarrhea after weaning. The
`appetite is poor, they fail to thrive, and if force-fed high-
`protein milk or formulas, they may go into coma. After
`infancy, they reject high-protein foods, grow poorly, and
`have enlarged liver and spleen, muscle hypotonia, and
`sparse hair. Osteoporosis is prominent, and fractures are
`not uncommon; bone age is delayed. The mental prognosis
`varies from normal development to moderate retardation;
`most patients are normal. Four patients have had psychotic
`periods. The final height in treated patients has been slightly
`subnormal or low-normal. Pregnancies are risky: Profound
`anemia develops, platelet count decreases, and severe
`hemorrhages during labor and a toxemic crisis have
`occurred, but the offspring are normal if not damaged by
`delivery-related complications. Acute exacerbations of
`
`A list of standard abbreviations is located immediately preceding the index in each
`volume. Aclditional abbreviations used in this chapter include: HHH = hyper-
`ornithinemia-hyperammonemia—homocitru11inuria; LDH = lactate dehydrogenase;
`LPI : lysinuric protein intolerance; MCAT-1 and MCAT—2 = mouse cationic amino
`acid transporter—1 and transporter—2, respectively; TBG = thyroxine—binding globulin.
`
`Piige 3 of 26
`
`hyperammonemia have not been a frequent problem in
`treated patients, but may have been the cause of the sudden
`death in one adult male after moderate alcohol ingestion.
`About two thirds of the patients have interstitial changes in
`chest radiographs. Some patients have developed acute or
`chronic respiratory insufficiency, which in a few has led to
`fatal pulmonary alveolar proteinosis and to multiple organ
`dysfunction syndrome. Patients present with fatigue, cough,
`dyspnea during exercise, fever, and, rarely, hemoptysis, and
`may also show signs of nephritis and renal insufficiency.
`One adult patient with pulmonary symptoms has been
`treated with high-dose prednisolone and is infremission over
`6 years after the occurrence of the symptoms. In another
`patient, bronchoalveolar lavages have produced immediate
`relief during several subacute exacerbations.
`. In LPI, the concentrations of the cationic amino acids in
`plasma are subnormal or low-normal, and the amounts of
`glutamine, alanine, serine, proline, citrulline, and glycine
`are increased. Lysine is excreted in urine in massive excess,
`and arginine and ornithine in moderate excess. Daily urine
`contains a mean amount of 4.13 mmol lysine (range 1.02 to
`7.00), 0.36 mmol arginine (0.08 to 0.69) and 0.11 mmol
`ornithine (0.09 to 0.13) per 1.73 m2 body surface area. The
`mean renal clearances are 25.7, 11.5, and 3.3 ml/min/
`1.73 m2, respectively; occasional values suggest net tubular
`secretion of
`lysine. Cystine excretion may be slightly
`increased. Blood ammonia and urinary orotic acid excre-
`tion are normal during fasting but are increased after
`protein meals. The serum urea level is low to normal, and
`lactate dehydrogenase, ferritin, and thyroid-binding globu-
`lin levels are elevated.
`. The transport abnormality is expressed in the kidney
`tubules, intestine, cultured fibroblasts, and probably in the
`hepatocytes, but not in mature erythrocytes. In vivo and in
`vitro studies of the handling of cationic amino acids in the
`intestine and kidney strongly suggest that the transport
`defect is localized at the basolateral (antiluminal) mem-
`brane of the epithelial cells. In vivo, plasma concentrations
`increase poorly after oral loading with the cationic amino
`acids, but also if lysine is given as a lysine-containing
`dipeptide. Dipeptides and other oligopeptides use a differ-
`ent transport mechanism not shared with that of free amino
`acids. The dipeptide thus crosses the lumi11al membrane
`normally, and is hydrolyzed to free amino acids in the
`cytoplasm of
`the enterocyte. A11 efflux defect at
`the
`basolateral membrane explains wl1y the dipeptide-derived
`lysine is unable to enter the plasma compartment in LPI.
`Direct measurements and calculations Q§w“Qi(Ek'_e§68§al
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`4934 PART 21 / MEMBRANE TRANSPORT DISORDERS
`
`lysine in intestinal biopsy specimens have
`fluxes of
`confirmed that the defect indeed localizes to the basolateral
`cell surface. Similar cellular localization of the defect in the
`
`kidney tubules is suggested by infusions of citrulline, which
`cause not only citrullinuria but also significant argininuria
`and ornithinuria. Because citrulline and the cationic amino
`
`acids do not sl1are transport mechanisms in the tubules,
`part of the citrulline is converted to arginine and then to
`ornithine in the tubule cells during reabsorption. A
`basolateral transport defect prohibits antiluminal efflux of
`arginine and ornithine, which accumulate and escape
`through the luminal membrane into the urine. The genetic
`mutations in LPI and possibly in all cationic aminoacid-
`urias apparently lead to kinetic abnormalities in the
`transport protein(s) of the cationic amino acids. This is
`suggested by the fact that increasing the tubular load of a
`single cationic amino acid by intravenous infusion increases
`its tubular reabsorption, but reabsorption remains sub-
`normal even at high loads. he other cationic amino acids are
`able to compete for the same transport site(s) also in LPI,
`but an increase in the load of one cationic amino acid
`frequently leads to net secretion of the others.
`The plasma membrane of cultured fibroblasts shows a
`defect in the trans-stimulated efflux of the cationic amino
`acids; i.e., their flux out of the cell is not stimulated by
`cationic amino acids present on the outside of the cell as
`efficiently as it is in the control fibroblasts. The percent of
`trans-stimulation of homoarginine efflux in the fibroblasts
`of the heterozygotes is midway between that of the patients
`and the control subjects.
`. The exact cause of hyperammonemia in LPI remains
`unknown. The enzymes of the urea cycle have normal
`activities in the liver, and the brisk excretion of orotic acid
`during hyperammonemia supports the view that N-acet-
`ylglutamate and carbamyl phosphate are formed in
`sufficient quantities. Low plasma concentrations of arginine
`and ornithine suggest that the malfunctioning of the cycle is
`caused by a deficiency of intramitochondrial ornithine. This
`hypothesis is supported by experiments in which hyper-
`ammonemia after protein or amino nitrogen loading is
`prevented by intravenous infusion of arginine or ornithine.
`Citrulline, a third urea cycle intermediate, also abolishes
`hyperammonemia if given orally, because, as a neutral .
`amino acid, it is well-absorbed from the intestine. Ornithine
`deficiency in LPI has recently been questioned because
`cationic amino acids and their nonmetabolized analogues
`accumulate in higher-than-normal amounts in intestinal
`biopsy specimens and cultured fibroblasts
`from LPI
`patients in vitro and the concentrations of the cationic
`amino acids in liver biopsy samples are similar or higher in
`the patients when compared to these concentrations in the
`control subjects. If hyperammonemia is not due to simple
`deficiency of ornithine, it could be caused by inhibition of
`the urea cycle enzymes by the intracellularly accumulated
`lysine; by a coexisting defect in the mitochondrial ornithine
`transport necessary for the function of the urea cycle; or by
`actual deficiency of ornithine in the cytoplasm caused by
`abnormal pooling of the cationic amino acids into some cell
`organelle(s), most likely lysosomes. The latter two explana-
`tions imply that the transport defect is expressed also in the
`organelle(s).
`including
`in practically all proteins,
`. Lysine is present
`collagen. Lysine deficiency may cause many of the features
`of the disease that are not corrected by prevention of
`hyperammonemia, including enlargement of the liver and
`spleen, poor growth and delayed bone age, and osteoporosis.
`Oral lysine supplements are poorly tolerated by the patients
`
`Page 4 of 26
`
`because of their poor intestinal absorption. s-N-acetyl-L-
`lysine, but not homocitrulline, efficiently increases plasma
`concentration of lysine in the patients, but acetyllysine or
`other neutral
`lysine analogues have not been used for
`supplementation.
`. Recently, a 622-amino-acid retroviral receptor (murine
`leukemia viral receptor REC1) with 12 to 14 potential
`membrane-spanning domains has been cloned. The physio-
`logical role of the receptor was soon found to be that of a
`cationic amino acid transporter at the cell membrane; the
`protein was hence renamed MCAT-1, mouse cationic amino
`acid transporter-1. The functional characteristics of the
`transporter are similar to those of system y+, a widely
`expressed Na+-independent transport system for cationic
`amino acids. The human counterpart of the mouse REC1
`gene, encoding the retroviral receptor-transport protein,
`has been assigned to chromosome 13q12-q14 and named
`ATRC1. MCAT-1 (and y"‘) activity is not expressed in
`rodent liver, but two other related cationic amino acid
`transport proteins,
`formed presumably as a result of
`alternative splicing—Tea (T cell early activation; expres-
`sed also in activated T and B lymphocytes) and MCAT-2—
`are probably responsible for the low-affinity transport of
`cationic amino acids that is characteristic of (mouse) liver.
`Studies addressing the ATRC1 gene as well as the Tea and
`MCAT'-:2 genes as candidate genes for LPI are under way.
`. Treatment
`in lysinuric protein intolerance consists of
`protein restrictioi and supplementation with oral citrulline,
`3 to 8 g daily during meals. Patients are encouraged to
`increase their protein intake modestly during citrulline
`supplementation, but aversion to protein in most patients
`effectively inhibits them from accepting more than the
`minimal
`requirement. The treatment clearly improves
`the growth and well-being of the patients. Pulmonary
`complications (interstitial pneumonia, pulmonary alveolar
`proteinosis, cholesterol granulomas, and respiratory insuf-
`ficiency) have occasionally responded to early treatment
`with high-dose prednisolone, or to bronchoalveolar lavages.
`No therapy is known for the associated renal disease and
`renal failure.
`
`. The clinical and biochemical findings in other cationic
`alninoacidurias differ slightly from those in lysinuric
`protein intolerance. The symptoms of the index case with
`hyperdibasic aminoaciduria type 1 resemble those of LPI,
`but
`the other affected members of
`the pedigree are
`clinically healthy. The Japanese patient with isolated
`lysinuria has severe growth failure, seizures, and mental
`retardation. Her transport defect is apparently limited to
`lysine, and hyperammonemia is not a feature of the disease.
`
`Perheentupa and Visakorpi described the first three patients with
`“familial protein intolerance with deficient
`transport of basic
`amino acids” in 1965 .1 The disease is now called lysinuric protein
`intolerance (LPI) (MIM 222700) or “hyperdibasic aminoaciduria
`type 2.”2‘5 Over 100 patients with this autosomal recessive
`disease have been described or are known to me; 41 of them are
`Finns or Finnish Lapps.6‘52 The incidence in Finland is 1
`in
`60,000 births but varies considerably within the country.253
`Patients of black and white American,
`Japanese, Turkish,
`Moroccan, Arab, Jewish, Italian, French, Dutch, Irish, Norwegian,
`Swedish, and Russian origin have also been described. The
`fascinating combination in the disease of urea cycle failure,
`expressed as postprandial hyperammonemia, and a defect in the
`transport of the cationic amino acids lysine, arginine, and ornithine
`in the intestine and kidney tubules has led to extensive studies of
`the mechanisms that link these two phenomena. The mechanisms
`are still partly unresolved, and the sequence of events leading to
`hyperammonemia is unclear. We can siinplifycywfigmgyvlgdgg by
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`CHAPTER 192 / LYSINURIC PROTEIN INTOLERANCE AND OTHER CATIONIC AMINOACIDURIAS '
`
`GENETIC DEFECT OF
`EPITHELIAL LYS, ARG & ORN TRANSPORT
`
`l INTESTINAL
`ABSORPTION
`
`I TUBULAR RE-
`ABSORPTION
`/
`DEFICIENCY OF
`ORN, ARG &
`LYS
`
`PROTEIN MAL-
`
`NUTRITION
`
`TRANSPORT INTO
`LIVER CELLS
`
`IMPAIRED UREA CYCLE
`
`POSTPRANDIAL HYPER-
`AMMONEMIA
`
`y
`NAUSEA, PROTEIN
`AVERSION
`SEIZURES, STUPOR
`COMA
`
`GROWTH FAILURE
`
`OSTEOPOROSIS
`
`HEPATOMEGALY
`
`Fig. 192-1 The suggested pathogenesis of lysine, arginine, Iand
`ornithine deficiency, hyperammonemia, and aversion to protein in
`LPI.
`
`saying that hyperammonemia is caused by “functional defi-
`ciency” of the urea cycle intermediates arginine and ornithine in
`the urea cycle4-“*14‘54 (Fig. 192-1). LPI has also been a productive
`model for studies of cellular transport: It is the first human disease
`where the transport defect has been localized to the basolateral\
`(antiluminal) membrane of the epithelial cells.55‘57 Further, in LPI
`the parenchymal cells show a defect in the trans-stimulated efflux
`of the cationic amino acids, suggesting that
`the basolateral
`membrane of the epithelial cells and the plasma membrane of the
`parenchymal cells have analogous functions.58’§9
`Recently, the first candidate gene for LPI, ATRC1, encoding a
`human cationic amino acid transporter, has been mapped to the
`long arm of chromosome 13 (l3q12—q14).6° Without further proof,
`it is intriguing to hypothesize how a mutation in this or in a
`functionally similar gene or in genes encodi g regulatory proteins
`of these transporters might lead to the 1ne1nbflme—selective cationic
`amino acid transport defect of LPI and to the complicated clinical
`features of the disease.
`,
`Several patients with variant forms of cationic aminoaciduria
`have been described in which the protein tolerance often is better
`than in LPI and the selectivity and severity of cationic amino—
`aciduria differs.23’25-33'51*62 In the report by Whelan and Scriver“
`only the history of the index case suggested hyperammonemia, but
`other members of the pedigree have been sympto1n—free. The
`inheritance of this hyperdibasic aminoaciduria type 1 is autosomal
`dominant, implying that the patients are heterozygous for LPI or
`another type of hyperdibasic aminoaciduria.
`
`CLINICAL ASPECTS
`
`Lysinuric Protein Intolerance
`Natural Course of the Disease. The gestation and delivery of
`infants with LPI has been L1neventful.4“6’9‘“-35 Breast—fed infants
`usually thrive because of the low protein concentration in human
`milk, but symptoms of hyperammonemia may appear during the
`neonatal period and reflect exceptionally low protein tolerance or a
`high protein content in the breast milk. Nausea, vomiting, and mild
`diarrhea appear usually within 1 week of weaning or another
`increase in the protein content of the meals. Soy-based formulas
`are perhaps slightly better tolerated than cow’s milk. The infants
`are poor feeders, cease to thrive, and have marked muscular
`hypotonia. The patient’s liver and spleen are enlarged from the
`neonatal periodvonward. The association of episodes of vomiting
`with high protein feeds is not always apparent to the parents and
`may remain unnoticed even by trained physicians for years. Thus,
`
`Page 5 of 26
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`the diagnosis frequently has been delayed until the school age or
`even adulthood.35=47’63
`Around the age of 1 year, most patients begin to reject cow’s
`milk, meat, fish, and eggs. The diet then mainly contains cereals
`cooked in water, potatoes, rice and vegetables, fruits and juices,
`bread, butter, and candies. The frequency of vomiting decreases on
`this diet, but accidental
`increases in protein intake lead to
`dizziness, nausea, and Vomiting. A few patients have lapsed into
`coma, to the point where the EEG became isoelectric when the
`children were tube-fed with high-protein foods.”-35’4°’41~47 Enteral
`alimentation and total parenteral nutrition may cause symptoms in
`patients who have remained undiagnosed, because the protein or
`amino acid loads often exceed patient’s tolerance. Prolonged,
`moderately increased protein intake may lead to dizziness,
`psychotic periods, chronic abdominal pains, or suspicion of
`abdominal emergencies.
`trau-
`frequently, often after minor
`Bone fractures occur
`ma.4v14~3°‘35’53‘66 In a Finnish series, 20 of 29 patients (69 percent)
`had suffered from fractures of the long bones or of compression
`fractures of the lumbar spine; 10 (34 percent) had had more than 2
`fractures during the
`l8—year
`fol1ow—up.63‘55 Most
`fractures
`occurred before the age of 5 years. Symptoms of osteoarthrosis
`- often begin at the age of 30 to 40 years. The radiologic signs of
`osteoporosis are usually severe before puberty but decrease with
`advancing age. The effect of citrulline therapy on osteoporosis is
`minimal.
`
`Our accumulating experience with the late complications
`associated with the disease,
`together with recent
`reports of
`patients from outside Finland, suggest that in a sizable proportion
`of the patients the classic symptoms of protein intolerance may
`remain unnoticed.
`Instead,
`the patients may present with
`interstitial lung disease or respiratory insufficiency," or have renal
`glomerular or glomerulotubular disease with or without renal
`insufficiency as the first clinical finding (see “Complications and
`Autopsy Findings” below).
`V
`
`Physical Findings. Muscular hypotonia and hypotrophy are
`usually noticeable from early infancy but improve with advancing
`age.35 Most patients are unable to perform prolonged physical
`exercises, but acute performance is relatively good. The body
`proportions of patients after the first couple of years of life are
`characteristic: the extremities are thin, but the front view of the
`body is squarelike with abundant centripetal subcutaneous fat. The
`hair is thin and sparse, the skin may be slightly hyperelastic, and
`the nails are normal. The liver is variably enlarged, and the spleen
`is often palpable and is large by ultrasound.
`the age of
`Patients who have remained undiagnosed until
`several years have had characteristics typical of protein-calorie
`malnutrition and frequently resemble patients with advanced
`celiac disease. The subcutaneous fat may be reduced and the skin
`“loose” and “too large for the body” (Fig. 192-2).
`The ocular fundi have been normal by ophtha1moscopy.35 Of
`20 patients studied, 14 had minute opacities in the anterior fetal Y
`suture of both lenses. In 10 patients, the opacities were surrounded
`by minute satellites. The opacities were never large enough to
`cause visual
`impairment and have remained stable,
`in some
`patients now for over 25 years. The mechanism underlying the lens
`abnormalities is unknown.“
`The dentition of the patients has been normal, and the patients
`do not appear to be especially prone to caries, despite the high
`carbohydrate content of the diet._
`
`for
`Growth. Birth weights and lengths have been normal
`gestational age, and postnatal growth is normal before weaning.
`The growth curves then begin to deviate progressively from the
`normal mean, and, at the time of diagnosis, 16 of 20 Finnish
`patients were more than 2 SD below the mean height, 12 patients
`were more than 3 SD, 6 patients more than 4 SD, 2 patients more
`than 5 SD, and 1 patient 6 SD below the mean.35 Skeletal
`maturation is considerably delayed.63’64 The bond§wnmlIEy<rr2mfil3e
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`4936 PART 21 / MEMBRANE TRANSPORT DISORDERS
`
`A
`
`t
`
`l92—2 Two children with LPI. The pictures were taken at the time
`Fig.
`of diagnosis. A, Child 12 years old. B, Child 6 years old. Note the
`prominent abdomen, hypotrophic muscles, and “loose” skin. The
`
`thorax of tile child in A is deformed and her trunk shortened because
`of osteoporosis and pathologic fractures of the vertebrae.
`\
`
`slowly and linearly without a pubertal catch—up spurt, and most
`patients have not reached skeletal maturity by the age of 20 years.
`The final height of the patients has almost invariably been closer to
`the normal than the height measured at the time of diagnosis,
`because of therapy and the late cessation of growth. The head
`circumferenceshave been normal for age.
`The body ,proportions are normal, but with advancing age the
`moderate centripetal obesity, which is present from early child—
`hood, becomes more obvious.
`
`Skeletal Manifestations and Bone Metabolism. Osteoporosis is
`often recognizable in skeletal radiographs and has occasionally
`been the leading sign of LPl.3°’63“65 Two-thirds of the patients
`have had fractures, half of which have occurred after insignificant
`trauma. All fractures have healed properly within a normal time. ‘
`The skull and sella turcica have been normal in roentgenograms.
`Over 70 percent of the patients have some skeletal abnor-
`malities, either osteoporosis, deformations, or early osteoarthro—
`sis.53‘55 In radiographs of 29 Finnish patients, osteoporosis was
`present in 13; the cortices of the long bones were abnormally thin
`in 5; the vertebrae had endplate impressions in 8; metaphyses were
`rickets—lil(e in 2; and cartilage showed early destruction in 3. The
`cortex of the metacarpal bones was characteristically thickened in
`7.54 Morphometric analyses of bone biopsy samples showed
`moderate to severe osteoporosis in eight of nine patients studied;
`trabecular bone and osteoid volume were markedly reduced.“
`After double-labeling of bones with tetracycline in vivo, barely
`identifiable single lines were detected, suggesting poor bone
`deposition;
`the findings resembled those in severe malnutri-
`tion.63”74 The number of osteoblasts and osteoclasts was low, and
`the extent of osteoid along the bone surfaces was low or normal in
`all specimens studied.
`Laboratory tests for evaluation of calcium and phosphate
`metabolism have given unremarkable results.35’63”65 Serum
`calcium and phosphate concentration, urinary excretion of calcium
`and phosphate, serum magnesium, estradiol, testosterone, thyroid-
`stimulating hormone, cortisol, vitamin D metabolites [25~(OH)2-
`D, 1,25-(OH)2-D and 24,25-(OH);-D], parathyroid hormone,
`calcitonin, and osteocalcin concentrations have all been within
`the reference range.
`
`Page 6 of 26
`
`The daily urinary excretion of hydroxyproline is significantly
`increased during pubertal growth, but half of the adult patients also
`have
`supranormal
`excretion
`rates
`(mean
`of
`all
`adults
`212 :: 103 umol/m2; adult reference range, 60 to 180 umoll
`m2).65 The serurrl hydroxyproline concentration is increased in
`almost all patients irrespective of age. Serum concentrations of the
`C—terminal propeptide of type I procollagen and of the N—terminal
`propeptide of type III procollagen have been normal
`in all
`Kpediatric patients, but the concentration of the latter increases
`during puberty and remains elevated in adult patients.
`The incorporation of labeled hydroxyproline into collagen was
`significantly decreased in cultured LPI fibroblasts as compared
`with age—matched controls at the ages of 5, 14, and 30 years, but
`therb was no difference at the age of 44 years.“ Morphometry of
`the collagen fibrils in electron microscopy showed no differences
`between patients and controls.
`
`Liver Pathology. In the youngest patients, the histologic findings
`in liver biopsy specimens have been normal, with only occasional
`fat droplets in the hepatocytes.8’35*63v75 In older patients, delimited
`areas in periportal or central parts of the liver lobules contained
`hepatocytes with ample pale cytoplasm and small pyknotic nuclei.
`In these cells, the glycogen content is decreased, and glycogen
`appears in coarse particles. At the borders of the abnormal areas,
`many nuclei are ghostlike and have central
`inclusion bodies
`staining positively with periodic acid-Schiff. Cytoplasmic fat
`droplets occur especially in the periportal areas. Children who died
`of alveolar proteinosis with multiple organ dysfunction syndrome
`have mostly shown extensive fatty degeneration of the liver but
`minimal or moderate cirrhosis. Inflammatory cells have always
`been absent in the liver biopsy samples.
`Liver changes
`in LPI may reflect generalized protein
`malnutrition, because in kwashiorkor
`liver
`fat
`synthesis
`is
`increased, apolipoprotein synthesis is decreased, and lipoprotein
`lipases are inhibited.“ Similar liver changes have also been
`induced in rats by lysine and arginine deprivation.77
`
`Performance in Adult Life. Mental development is normal in
`most subjects. Performance is decreased, particularly in patients
`with known histories of prolonged hype1'a1nmQm,HgaEA_l§m§her,
`Lupin v. Horizon
`IPR2016-00829
`
`
`
`Page 6 of 26
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`Owner Ex. 2003
`Lupin v. Horizon
`IPR2016-00829
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`

`
`CHAPTER 192 / LYSINURIC PROTEIN INTOLERANCE AND OTHER CATIONIC AMINOACIDURIAS
`
`about 20 percent of the patients with LPI reported in the literature
`or otherwise known to me are mentally retarded. Convulsions are
`uncommon, but periods of
`stupor have occasionally been
`misinterpreted as psychomotor seizures.” Four patients have had
`psychotic periods, which have clearly been precipitated by
`prolonged moderate hyperammonemia.”
`Neuropsychologic evaluation of the patients suggests that
`mathematical and other abstract skills are particularly vulnerable
`to hyperammonemia. Treatment with a low-protein diet and
`citrulline supplementation”’14’63 (see “Treatment” below) has
`significantly improved the life quality of the patients. Episodes of
`vomiting and other signs of hyperammonemia have become a rare
`exception. The patients who underwent prolonged periods of
`hyperammonemia in early infancy and childhood and who
`appeared severely retarded at the first presentation have consider-
`ably and continuously improved their performance during therapy.
`All Finnish patients are now able to take care of the activities of
`daily life, and none of them is institutionalized. The most severely
`retarded patient, who had an IQ of 40 at the age of 12 years, lives
`now at the age of 40 in the custody of another family apd is
`capable of taking care of her daily activities; she also works in a
`protected environment outside the home for a few hours a day and
`helps routinely in the household. She is talkative, happy, and
`socially active. At the other end of the spectrum, one patient has
`graduated from a medical school, works successfully as an
`internist, is married, and is a mother of one. Several other patients
`have also graduated from high school or other secondary schools
`and are permanently employed. The physical fitness of the patients
`is fair, but their capacity for prolonged heavy work and physicall
`endurance is clearly limited. One patient worked as a construction
`worker in a building company for a few years, but found the job
`too heavy; another has been an active jogger for years and is
`capable of running 15 km without problems. The oldest patient in
`Finland is now 49 years of age and retired 7 years ago because of
`back problems. He is mentally and physically active and takes care
`of the household duties of a small farmhouse. A Finnish-born
`patient in Sweden is now 58 years old.‘6’2"29 One male and seven
`female patients are married.
`
`Pregnancies of the Patients. The seven mairied women have had
`fifteen pregnancies. One of the mothers was treated ‘during the
`pregnancy only with protein restriction;
`the other ‘received
`citrulline supplementation (8 to 14 pills containing 0\414 g L-
`citrulline daily during meals). Anemia (hemoglobin < 8.5 g/dl)
`occurred in all, and the platelet count decreased to less than
`50 X 103/mm3. A severe hemorrhage complicated two deliveries
`in one patient. Another patient had severe toxemia in her second
`pregnancy. The blood pressure increased to crisis Values and she
`had prolonged convulsions and unconsciousness, but she recov-
`ered totally. In a third patient, an ultrasound-guided amniotic fluid
`puncture led to a bleed and loss ‘of the fetus at 35 gestational
`weeks. Despite the mothers’ anemia and severely decreased
`platelet count, other pregnancies and deliveries have been‘
`uneventful.
`
`Of the 14 living children born to the patients, 13 are well at the
`age of 0.5 to 14 years. One child, whose delivery was complicated
`by a severe maternal hemorrhage, has hemiplegia and slightly
`delayed mental development, and another one was late in learning
`to speak but has later developed well.
`One male patient has a healthy son.
`
`Complications and Autopsy Findings. Since th