Carlo Dionisi Vici, Convegno Mitocon 2014

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Carlo Dionisi Vici, Convegno Mitocon 2014

  1. 1. 1 Terapie personalizzate: i cocktails di farmaci e gli integratori Mitocon 2014 Carlo Dionisi-Vici U.O.C. Patologia Metabolica Dipartimento di Medicina Pediatrica carlo.dionisivici@opbg.net
  2. 2. 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
  3. 3. ac. grassi zuccheri proteine FFA G6P piruvato glucosio lattatoacil-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
  4. 4. 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
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. 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 is9 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
  9. 9. Enzimi dipendenti dalla Tiamina
  10. 10. L’effetto della Tiamina in caso di deficit secondario Maiorana 2014
  11. 11. 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
  12. 12. 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 4 pyruvic 2-OH-isovaleric 2-keto isovaleric 2-keto 3-CH3-valeric 2-keto isocaproic lactic IS 2-keto glutaric IS Carrozzo 2014 submitted
  13. 13. 43 215 245 387 50973 3181 I40LfsX4 G461E Carrozzo 2014 submitted
  14. 14. 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
  15. 15. cytosol FFA fatty acyl-CoA carnitine fatty acid oxidation acetyl-CoA βOX- cyclee- transfer fatty acylCoA carnitine Carnitine cycle ketones CO2+H2O ketogenesis mito
  16. 16. Deficit Primario di Carnitina No terapia carnitina 3 g/die Tein 1990; Lamhonwah 2002
  17. 17. 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
  18. 18. 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
  19. 19. CINZIA deficit di VLCAD
  20. 20. carnitina acil-carnitina acil-CoA Le acilcarnitine: una finestra sul mitocondrio 16/37
  21. 21. 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 Intensity,cps CTD MCAD SCAD VLCAD IVA HMG GA1-GA2 MMA-PA CACT LCHAD-MTP Screening acilcarnitine in MSMS
  22. 22. Enhance electron transfer within the respiratory chain • Riboflavin (FAD precursor) • Niacin (NADH precursor) CoQ (Idebenon, EPI-743) Vitamin E
  23. 23. Coenzyme Q10 • Primary CoQ deficiencies (mutations in enzymes involved in CoQ synthesis) • Secondary CoQ deficiencies (mutations in other genes)
  24. 24. • 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
  25. 25. 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
  26. 26. 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 12biotin biotin thiamine Vitamins in OAs
  27. 27. PCC carnitine propionyl-carnitine carnitine + carnitine CoA Carnitine buffer function in OAs
  28. 28. J Pediatr 1996 u. 5-oxoproline156 2145 17 pl. GSH uM0,3 0,005 0,1
  29. 29. GSH:structure and function NH3 + C H2 C O- O H2 C C O H H N 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
  30. 30. 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
  31. 31. • 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
  32. 32. 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
  33. 33. Pastore MGM 2013 EPI743: a treatment for SUCLA2 (& Leigh syndrome)?
  34. 34. 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)?
  35. 35. •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
  36. 36. Cobalamin Rutsch 2009 Inherited cobalamin defects
  37. 37. Fischer et al.
  38. 38. Pastore et al. GSH in lymphocytes from 18 cblC patients
  39. 39. C. Dionisi-Vici PI Retinopathy – optic atrophy - nistagmous
  40. 40. 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

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