metabolic disorders · cns symptoms, poor growth, failure to thrive, developmental delays, specific...
TRANSCRIPT
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Metabolic Disorders
KNH 413
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Metabolic Disorders
� Inborn errors of metabolism – group of diseases that affect a wide variety of metabolic processes; defective processing or transport of amino acids, fatty acids, sugars or metals caused by a defect in the activity of an enzyme
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Metabolic Disorders
� Inheritance� Most inborn errors are autosomal recessive
� Carrier parents have a 25% chance of an affected child� Mutations – permanent, transmissible changes in the genetic
material� Differences in degree of stability and activity of enzyme� Severity described by time of onset� Classical form most severe
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Metabolic Disorders
� Impaired Metabolism - Pathophysiology� Deficient or absent enzyme activity or� Changes in binding site of cofactor� Precursors accumulated d/t block or impaired feedback
inhibition� Toxic metabolites produced as a result of the build up� Or deficiency of needed end product� Secondary nutritional deficiencies
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Metabolic Disorders
� Diagnosis/ Newborn Screening� Nonselective screening – screening all newborns for a limited
number of common inborn errors� Selective – testing of an individual known to be at increased
risk (e.g. sibling)� All states screen for PKU, variability in other disorders
screened� Tandem mass spectroscopy – allows clinicians to screen for >
30 disorders
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Metabolic Disorders� Clinical manifestations
� Usually appear 24 hours or more after birth, attributed to ingestion of precursor substrate of defective enzyme
� CNS symptoms, poor growth, failure to thrive, developmental delays, specific neurological deficits
� May have blatant signs (i.e. unusual odor)
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Metabolic Disorders� Clinical manifestations – diagnosis
� Laboratory studies � Routine
� Hypoglycemia, acid-base balance, hyperammonemia, ketosis
� Specialized studies� Require special lab
� Directed analysis for amino acids or organic acids
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© 2007 Thomson - Wadsworth
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Metabolic Disorders� Approaches to Treatment
� Acute therapy� Correction of acid-base balance and hydration of immediate
importance
� Maintenance of adequate kcal to prevent tissue catabolism
� Offending metabolites restricted
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Metabolic Disorders� Approaches to Treatment
� Chronic Therapy� Restriction of precursors� Replacement of end products
� Providing alternate substrates for metabolism
� Use of scavenger drugs to remove toxic by-products� Supplementation of vitamins or other cofactors
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Amino Acid Disorders
� Phenylketonuria (PKU)
� Isovaleric acidemia (IVA)
� Maple syrup urine disease (MSUD)
� Others
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© 2007 Thomson - Wadsworth
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Amino Acid Disorders� Phenylketonuria (PKU) – most common
� Absence of phenylalanine hydroxylase enzyme� Inability to convert phenylalanine to tyrosine� Tyrosine becomes conditionally essential
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Amino Acid Disorders� Phenylketonuria (PKU)
� Results in metal retardation, severe behavioral problems, seizures, eczema
� Musty or mousy odor� Toxic to brain – demyelination of white matter� Decreased production of serotonin, epinephrine,
norepinephrine, dopamine, GABA
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Amino Acid Disorders� PKU – Nutrition Interventions
� Restriction of dietary protein� Synthetic formula supplying all essential amino acids except
offending amino acids� Blood phenylalanine target levels more restrictive for
children up to age 12
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Amino Acid Disorders� PKU – Nutrition Interventions
� Assess kcal and protein needs� Amount of allowed phenylalanine determined by enzymatic
activity and blood levels� Allow as much protein as possible for adequate growth from
fruits, vegetables, limited amounts of grains� Balance provided by metabolic formulas
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Amino Acid Disorders� PKU – Nutritional Concerns
� Risk for nutritional deficiencies� Growth retardation� Bone status� Amino acid deficiencies� Overrestriction� Metabolic control during pregnancy
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Amino Acid Disorders� PKU – Adjunct Therapies
� Antibiotics� Carnitine� Sodium benzoate� Sodium phenylbutyrate
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Urea Cycle Disorders
� Impaired capacity to excrete nitrogen in the form of urea
� Cascade of enzymatic reactions which converts ammonia to urea can be blocked
� Or a depletion of an amino acid essential to the function of the cycle can result
� Causing hyperammonemia
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© 2007 Thomson - Wadsworth
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© 2007 Thomson - Wadsworth
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Urea Cycle Disorders
� Hyperammonia may cause loss of appetite, cyclical vomiting, lethargy, learning difficulties, behavioral abnormalities, severe retardation
� May require daily assistance, tube feedings, and wheelchairs
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Urea Cycle Disorders� Acute Treatment
� Hemodialysis � Sodium benzoate and sodium phenylacetate to scavenge
excess ammonia� IV fluids, avoiding overhydration� Caloric supplementation� Glucose, intralipids� Complete protein restriction for 24-48 hours
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Urea Cycle Disorders� Nutrition Interventions
� Protein adjustment to account for severity, age, growth rate, and individual preferences without any extra
� Supplemental arginine for most� May use essential amino acid mixture to replace natural
sources� 25-30% of protein intake should be essential amino acids
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Urea Cycle Disorders� Nutrition Concerns
� Amino acid intake must be balanced� Risk of micronutrient deficiency
� Iron, zinc
� Adequate energy intake� Nutrition support may be needed� Continuous monitoring� See flow sheet example
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Urea Cycle Disorders� Adjunct therapies
� Liver transplantation� Alternative pathway therapy
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Mitochondrial Disorders
� Results from defects either in the respiratory chain or from defects affecting overall number and function of the mitochondria
� MELAS or NARP
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© 2007 Thomson - Wadsworth
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Mitochondrial Disorders
� Diagnosis� DNA mutation testing� Skin and muscle tissue histological and biochemical analysis
� Disorders include� Fatty acid transport disorders� Fatty acid oxidation defects� Pyruvate complex disorders� Respiratory chain defects
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Mitochondrial Disorders
� Respiratory Chain � Five complexes that undergo changes in their oxidative
state to produce ATP
� Defects lead to:� Decreased energy production
� Hypotonia, developmental delay, failure to thrive
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Mitochondrial Disorders
� Nutrition Intervention� No definite treatment� Use of vitamin cofactors in pharmacological
amounts � 100-1000 times DRI for age� Riboflavin and thiamin – cofactors� Vitamin E and lipoic acid – antioxidants� Vitamins C, K, CoQ10 – artificial electron receptors and
transporters
� Frequent feedings recommended
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© 2007 Thomson - Wadsworth
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Mitochondrial Disorders
� Adjunct therapies� Carnitine and glycine – conjugate with toxic metabolites,
removing them from body
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Disorders of Vitamin Metabolism
� Needed as cofactors for enzymatic reactions, antioxidants, or electron receptors
� Pharmacologic dose may be sufficient to maintain normal enzymatic function
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Disorders of Vitamin Metabolism� Nutritional Interventions
� Methylmalonic acidemia – responsive to B12
� Holocarboxylase synthetase deficiency and biotinidase deficiency - responsive to biotin
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© 2007 Thomson - Wadsworth
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Disorders of Vitamin Metabolism
� Nutritional Concerns� Pharmacological doses of vitamins should be treated as “drugs”
� Use of “megavitamin” supplements in random fashion discouraged
� Toxicity a concern for fat-soluble vitamins� Compliance� Cost
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Disorders of Carbohydrate Metabolism
� Problems processing simple sugars galactose and fructose, or glycogen storage diseases
� Summary of disorders and clinical symptoms
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Galactosemia
� Enzyme defect in galactose metabolism leading to failure to thrive, hepatomegaly, life-threatening sepsis in newborn period� Vomiting, jaundice upon initiation of milk feedings� Anorexia, failure to gain weight or grow� Cirrhosis, ascites, edema, bleeding problems,
enlarged spleen if milk feedings continue
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Galactosemia
� Many states screen for it
� Defect is in conversion of galactose to glucose 1 phosphate
� G1P accumulates in tissue
� Clinical manifestations result
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Galactosemia
� Nutrition Interventions� Exclusion of galactose/ lactose from diet
� Immediate reversal of symptoms results
� Exclusion of human milk, cow’s milk …� Substitution of casein hydrolysate-containing
formula� Infant soy formulas� Learn other potential dietary and drug sources of
galactose� See Table 28.12
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© 2007 Thomson - Wadsworth
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Galactosemia
� Nutrition concerns� Provision of alternative sources of missing nutrients: vitamin
D, calcium� Calcium supplements� Meet kcal, protein, vitamin and mineral needs
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Hereditary Fructose Intolerance
� Deficiency of fructose 1 phosphate aldolase
� Accumulation in tissues containing fructokinase, causing depletion of inorganic phosphate and ATP
� Fructose-induced hypoglycemia
� d/t ingestion of fructose, sucrose, or sorbitol in diet
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Hereditary Fructose Intolerance
� Clinical manifestations� Vomiting� Poor feeding, diarrhea, failure to thrive� Hepatomegaly, bleeding tendency, jaundice, edema,
ascites
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Hereditary Fructose Intolerance
� Nutrition Intervention� With fructose-free diet vomiting and bleeding tendency
disappear immediately� Hepatomegaly and steatosis will disappear between 5-10
years
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Hereditary Fructose Intolerance
� Nutrition Concerns� Vitamin supplement may be indicated� Requires strict avoidance for life of all dietary fructose and
sucrose� Aversion to sweets may develop
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Glycogen Storage Diseases� Deficiencies of enzymes that regulate the synthesis or
degradation of glycogen (8 types)
� Most related to deficient activity in conversion of glycogen to glucose 6 phosphate
� Results in abnormal glycogen deposition in liver and muscle
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Glycogen Storage Diseases� GSD1 most commonly diagnosed
� Deficiency of enzyme glucose 6 phosphatase resulting in hypoglycemia
� Low blood glucose results in short periods of fasting (2-4 hours)
� Elevations in lipids, lactate, uric acid
� Hepatomegaly
� Chronic lactic acidosis, poor growth
� Osteoporotic bones, delayed bone age
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Glycogen Storage Diseases� Nutrition Interventions – GSD1
� Frequent oral feedings, high in CHO to maintain glucose > 70 mg/dL
� Daytime meals followed by continuous drip nocturnal enteral feedings
� Cornstarch - 1-2 g/kg body weight every 3-6 hours
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Glycogen Storage Diseases� Nutrition Concerns – GSD1
� Availability of high-CHO snacks at all times� Illness can be life threatening� Adjustment to decreased oral intake� Multivitamin/ mineral supplement� Calcium and iron supplementation
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Disorders of Fat Metabolism
� Defect in enzymes which allows transport of fatty acids into the mitochondria; specific to short-, medium- or long-chain fatty acids
� Fatty acids not utilized resulting in hypoglycemia, hyperammonemia, death
� MCADD most common
� Deficiencies of carnitine metabolism
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© 2007 Thomson - Wadsworth
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© 2007 Thomson - Wadsworth
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Disorders of Fat Metabolism
� Nutrition Intervention� Prevention of fasting� Limiting intake of fatty acids� Providing alternate substrate for metabolism (CHO,
protein)� Include complex CHO vs. simple to maintain euglycemia
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Disorders of Fat Metabolism
� Nutrition Intervention� LCHADD – restrict long-chain fatty acids to no more than
15% of kcal� Supplement with MCT� MCADD – avoidance of fasting, feed every 3 hours� Monitor blood glucose levels� Do not use MCT oil
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Disorders of Fat Metabolism
� Nutrition Concerns� Overrestriction of fat� Essential fatty acid deficiency� Excessive weight gain� Maximize fluid intake� Carnitine used to detoxify, given as supplement