Glutaric aciduria

Stefan Kolker MD (Dr. Kolker of the University of Heidelberg, Germany, has no relevant financial relationships to disclose.)
Tyler Reimschisel MD, editor. (Dr. Reimschisel of Vanderbilt University has received contracted research grants from Shire and Vtesse.)
Originally released November 28, 1994; last updated January 22, 2017; expires January 22, 2020

This article includes discussion of glutaric aciduria, glutaric acidemia, glutaric aciduria type I, glutaryl-CoA dehydrogenase deficiency. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Glutaric aciduria or acidemia type I is biochemically characterized by an accumulation of putatively neurotoxic glutaric and 3-hydroxyglutaric acid and nontoxic glutarylcarnitine. The majority of untreated patients manifests with dystonia due to striatal injury in infancy. The implementation of newborn screening programs has significantly reduced the manifestations of neurologic disease from this condition. In this update, the author discusses the age- and organ-specific expression patterns of glutaryl-CoA and the updated recommendations for diagnosis, therapy, and care.

Key points

 

• The precondition for preventing striatal injury is identifying patients when asymptomatic and starting metabolic treatment immediately.

 

• Intensified emergency treatment should be started without delay and before neurologic symptoms occur during each putatively threatening episode, such as infectious disease.

 

• Treatment should be initiated and patients should be followed by an interdisciplinary team of metabolic specialists, dieticians, psychologists, neurologists, physical therapists, and occupational therapists.

Historical note and terminology

Glutaric aciduria or acidemia type I (glutaryl-CoA dehydrogenase [GCDH] deficiency) was first described in 1975 (Goodman et al 1975) and is caused by inherited deficiency of GCDH (EC 1.3.99.7), an essential enzyme for the catabolism of lysine, hydroxylysine, and tryptophan (Christensen 1993; Fu et al 2004).

Retrospective and prospective studies include patients from 2 North American genetic isolates with a high carrier frequency: the Amish Community (Strauss et al 2003; Strauss et al 2007) and the Saulteaux/Ojibwa (Oji-Cree) Indians (Greenberg et al 2002) as well as European patients (Hoffmann et al 1991; Hoffmann et al 1996; Busquets et al 2000; Kyllerman et al 2004). A metaanalysis of this disease evaluating 42 published case reports describing 115 patients has been reported (Bjugstad et al 2000). An international cross-sectional study enrolling 279 patients has also been published (Kolker et al 2006). A guideline for diagnosis and management has been introduced (Kolker et al 2007a), and the beneficial effect of using this guideline has been confirmed (Heringer et al 2010). Guideline recommendations have since been updated (Kolker et al 2011). A revision of the proposed recommendations has confirmed the previous recommendations for diagnosis, therapy, and care (Boy et al 2017). The EIMD Patient Registry is an international registry for intoxication type metabolic diseases and includes follow-up data for over 200 patients (Kolker et al 2015).

These reports greatly broadened the clinical spectrum of glutaric aciduria type I to include children with nonprogressive extrapyramidal syndromes and even biochemically affected but clinically normal children with glutaric aciduria type I. At present, more than 500 patients have been reported worldwide. As a result, glutaric aciduria is now recognized as 1 of the most common identifiable inborn errors of metabolism associated with progressive or nonprogressive extrapyramidal disease. Development of tandem mass spectrometry-based programs for expanded neonatal screening has provided the opportunity to diagnose a variety of children before onset of acute encephalopathy (Lindner et al 2006) and to start prospective follow-up studies (Strauss et al 2003; Kolker et al 2007b; Bijarnia et al 2008; Boneh et al 2008).

The human GCDH gene was assigned to chromosome 19p13.2 in 1994 (Greenberg et al 1994).

During the last decade, a variety of studies have focused on the pathogenetic mechanisms involved in acute neurodegeneration of this disease using in vitro and in vivo models (Kolker et al 2004). Gcdh-deficient mice, an animal model for this disease, have been developed and are still under investigation (Koeller et al 2002; Sauer et al 2005; Sauer et al 2006; Sauer et al 2011; Zinnanti et al 2006; Zinnanti et al 2007).

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