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Application of stable isotope tracers to examine phenylalanine metabolism and protein requirements in children with phenylketonuria (pku) Turki, Abrar Mohammed


Phenylketonuria (PKU) is an inherited inborn error of phenylalanine (PHE) metabolism caused by deficiency of hepatic enzyme phenylalanine hydroxylase (PAH). Therefore, PHE accumulates in plasma leading to mental retardation and developmental delay. Kuvan® (Sapropterin dihydrochloride), a synthetic form of tetrahydrobiopterin (BH₄), has been shown to reduce plasma PHE levels in PKU, but not all patients respond to sapropterin treatment. The major mode of treatment remains nutritional management with dietary restriction of PHE and provision of sufficient protein. The dietary protein requirement in children with PKU remains unknown. Therefore the objectives of the current thesis were: 1) to identify sapropterin responsiveness in PKU children using a minimally invasive L-[1-¹³C] phenylalanine breath test (¹³C-PBT), and 2) to determine protein requirements in PKU children using the indicator amino acid oxidation (IAAO) technique. Experiment 1- Nine children with PKU (5-18y) underwent ¹³C-PBT tracer protocols twice, once before and once after 1-2 weeks of sapropterin therapy. ¹³CO₂ was measured using isotope ratio mass spectrometer (IRMS). The study protocol was tested in healthy children (n= 6) as proof of principle. Experiment 2- Four PKU children (5-18y) were recruited to participate in test protein intakes (ranging from deficiency to excess 0.2 – 3.2 g/kg/d) with the IAAO protocol using L-[1-¹³C] leucine, followed by collection of breath and urine samples over 8 hours. Results 1- ¹³CO₂ productions in all children with PKU pre-sapropterin treatment were low, except in one child (PKU04). Five children with PKU showed a significantly higher peak enrichment after sapropterin treatment at 20min. Three PKU children had no change in ¹³CO₂ production post sapropterin therapy. Results 2- The mean protein requirement, identified using 2-phase linear regression analysis was determined to be 1.85 g/kg/d. This result is significantly higher than the most recent PKU recommendations (2014) (1.14 – 1.33g/kg/d, based on 120-140% above current recommended dietary allowance RDA). These findings show that the ¹³C-PBT can be a minimally invasive method to examine in vivo PHE metabolism in PKU children responsive to sapropterin therapy. Also, current recommendations for optimal protein intake may be underestimated.

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