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PubMed1976

Propionic acidemia and hyperlysinemia in a case with ornithine transcarbamylase (OTC) deficiency.

A female infant with episodic hyperammonemia due to a disorder of the urea cycle and who had hyperlysinemia and an unusual elevation of short chain fatty acids, mainly propionate, is described. Both occurred apparently only during attacks of hyperammonemia. Propionic acidemia was ruled out by enzyme studies. OTC deficiency was diagnosed on the basis of: 1) decreased enzyme activity in leukocytes;2) hyperammonemia in response to protein intakes in excess of 2.0 g/kg/day; 3) orotic aciduria in the patient and her asymptomatic mother; 4) suggestive evidence of x-linked dominant inheritance; and 5) exclusion of citrullinemia, argininosuccinic aciduria, argininemia, and disorders of lysine metabolism that are associated with hyperammonemia. Homocitrullinuria, presence of epsilon-N-acetyl-l-lysine in urine, and absence of saccharopine indicate deficiency of the saccharopine pathway of lysine degradation. However, alpha-ketoglutarate reductase was normal in fibroblasts. Since these metabolites were observed only in conjunction with hyperammonemia but not after a lysine load, we suggest that there was competition between ammonia and lysine for alpha-ketoglutarate. The link between disorders of the urea cycle and short chain fatty acid metabolism remains unexplained..

Acid-Base Imbalance↗

PubMed1978

Studies of the cause and treatment of hyperammonemia in females with ornithine transcarbamylase deficiency.

Assay of ornithine transcarbamylase (OTC) activity in multiple small bits of liver (approximately 5 mg) that were obtained from a single surgical biopsy in a patient with OTC deficiency revealed a 10- to 40-fold variation in enzyme activity. Similar studies with control autopsy liver specimens varied 2.5-fold at most. The greater variation in the patient with OTC deficiency probably is due to sampling of clusters of normal or abnormal hepatocytes that resulted from inactivation of either the abnormal or normal X chromosone. Enzyme activity assayed on small liver biopsy specimens may not be representative of the entire liver in female patients with OTC deficiency. The hyperammonemia in individuals heterozygous for OTC deficiency may be due in part to shunting of blood through multiple "metabolic portosystemic shunts." Treatment of a girl who has OTC deficiency with a low-protein diet, a low-protein diet supplemented with oral essential amino acids, and a low-protein diet plus oral ketoacids of essential amino acids, on a separate occasion, a low-protein diet was compared to a low-protein diet plus lactulose. The low-protein diet plus oral ketoacid supplementation resulted in the best metabolic control of the patient's disease. On the other hand, paradoxical transient hyperammonemia was observed after the intarvenous administration of ketoacids to two acutely ill female patients with OTC deficiency.

Amino Acids, Essential↗

PubMed2026

A brief history of gene therapy for ornithine transcarbamylase deficiency.

Gene therapy encompasses the use of nucleic acids, including DNA and RNA, as therapeutic agents. This broad category includes approaches that permanently modify the genome to correct pathogenic variants, as well as strategies that restore gene expression without altering genomic DNA. In ornithine transcarbamylase (OTC) deficiency, the most common urea cycle disorder, the goal of somatic gene therapy is to restore hepatic expression of functional OTC enzyme and thereby reestablish urea cycle activity. Both viral and non-viral delivery platforms have been investigated in preclinical models and clinical studies to achieve therapeutic OTC expression. Despite contemporary medical therapy, individuals with OTC deficiency (OTCD) remain at risk for recurrent hyperammonemia which may result in neurocognitive impairment and reduced quality of life. Novel therapy that restores liver OTC expression and lessens chronic disease burden is highly desired. In this manuscript, we summarize the history of gene therapy development for OTC deficiency, spanning early preclinical investigations to contemporary clinical trials. Although a definitive cure through gene therapy has not yet been achieved, substantial progress has been made toward the development of safe and effective liver-directed nucleic acid therapeutics for this disorder.

Adeno-associated virus vector↗

PubMed1979

Atypical clinical course of ornithine transcarbamylase deficiency due to a new mutant (comparison with Reye's disease).

A male infant with ornithine transcarbamylase (OTC) deficiency is described who was relatively symptom free for 4 months, gradually developed severe spasticity due to cerebral atrophy, and died at 13 months of age. Liver OTC activity was 1.5% of the normal mean. The mutant OTC showed an increased apparent Km for ornithine and an increased pH optimum. These kinetic findings fail to explain the atypical clinical course. The clinical picture of patients with genetic OTC deficiency who present during acute exacerbations together with the elevation of serum glutamic oxaloacetic transaminase and microvesicular fat accumulation in liver, as seen in this case, may suggest Reye's syndrome; however, electronmicroscopic examination of this patient suggested that the normal appearance of mitochondria helps to distinguish the two.

Adult↗

PubMed2026

Functional editing of the OTC locus by targeted integration with phenotype correction and restoration of endogenous expression patterns.

Here, we report highly efficient functional repair of the ornithine transcarbamylase (OTC) locus in mutant mouse and human hepatocytes in vivo using a dual adeno-associated virus system delivering CRISPR-Cas9 editing reagents and a promoterless donor for targeted integration. The approach was mutation agnostic and targeted intronic sequences to prevent inadvertent inactivation of hypomorphic alleles. Notably, in a murine model, we corrected the metabolic defect and simultaneously achieved liver-wide restoration of physiological metabolic zonation of Otc expression by capturing native cis-acting regulatory elements. The effectiveness of this approach was confirmed using a universally configured therapeutic cassette in patient-derived primary human hepatocytes in vivo. These data provide a powerful template to guide further optimization of this approach and, given the high editing efficacy required for phenotypic effect in OTC deficiency, have broader relevance to other liver disease phenotypes.

Animals↗

PubMed1976

Ornithine transcarbamylase deficiency: enzyme studies on a further case and a method of diagnosis using plasma enzyme ratios.

The activities of the urea cycle enzymes in the liver of a female patient with hyperammonemia were determined (Table 1). Ornithine transcarbamylase (OTC, EC. 2.1.3.3) was reduced to 5-10% of normal and the residual enzyme showed an apparent Kmorn of 0.69 (normal 0.37 +/- 0.10) mmol liter. The pH dependence was normal. The patient's mother also showed hyperammonemia but was not clinically affected. Consideration of the genetics of the disease suggested that many female patients should have a mixture of normal and mutant enzymes. Electrophoresis of the patient's liver extract showed an additional band of OTC activity probably due to this mutant enzyme. The ratio of plasma glutamate-pyruvate transaminase to OTC was abnormal in four clinically affected patients with OTC deficiency (Fig. 4B) but not in two of their mothers without clinical signs.

Alanine Transaminase↗

PubMed1976

X-chromosome inactivation in human liver: confirmation of X-linkage of ornithine transcarbamylase.

Histochemical assay for ornithine transcarbamylase (OTC) activity in fixed frozen hepatic sections from a woman heterozygous for OTC deficiency revealed two populations of hepatocytes: those with normal activity and those with no activity. This observation, in conjunction with data from previous family studies, confirms the hypothesis that the gene for OTC is X-linked. It also provides the first cytologic demonstration of cellular mosaicism for a liver-specific cell product.

Biopsy↗

PubMed1978

Treatment of complete ornithine transcarbamylase deficiency with nitrogen-free analogues of essential amino acids.

A male infant with complete hereditary deficiency of hepatic ornithine transcarbamylase was fed a low-protein diet (1 gm/kg/day) supplemented with nitrogen-free analogues of essential amino acids from the age of 2 days until his death at 5 months. Blood ammonia and plasma acid concentrations were maintained in the near normal range during most of his lifetime. Growth and development were entirely normal. Abrupt, unprecipitated hyperammonemia, which could not be reversed by intensive treatment, led to his death. To our knowledge, this child lived longer than any previously reported infant with OTC deficiency of this severity.

Amino Acids↗

PubMed1976

Autosomal genetic control of the activity of a new variant ornithine transcarbamylase in chicken kidney.

The mode of inheritance of the gene for chick kidney ornithine transcarbamylase (OTC), found previously as a genetic variant, was investigated. White Leghorn B line males homozygous for the allele for the variant OTC gene were selected using the California Gray breed, having a near-absolute deficiency of the enzyme. Then further crosses of the two breeds were made. The mean value of the OTC level of F1 progeny was about 170 units. Chicks from the backcross generation were divided into two groups, of high activity and low activity, in a ratio of 1:1. F2 chicks were divided into three groups: one-fourth of the chicks were classified as a "super high" group, one-half were "high," and the remaining one-fourth were "low"; the mean values for OTC level were 356.7, 196.4, and 15.6 units, respectively. From these results, it was suggested that the variant OTC represents a simple autosomal incompletely dominant trait.

Animals↗