Acute Nutritional Ketosis in VLCAD Deficiency
Study Details
Study Description
Brief Summary
To test if a ketone-ester based drink can boost muscle mitochondrial function in vivo in patients with VLCADD in order to establish a rational basis for therapeutic use in this disorder.
| Condition or Disease | Intervention/Treatment | Phase |
|---|---|---|
|
N/A |
Detailed Description
Exertional rhabdomyolysis is a common symptom in very long-chain acylCoA dehydrogenase deficient (VLCADD) patients. Failing muscle ATP homeostasis, due to impaired fatty acid oxidation, is the most likely cause. Therefore, supplementation with an alternative energy substrate to boost ATP homeostasis, such as an exogenous ketone ester (KE) drink, could be a therapeutic option. Previous results suggest that KE is preferentially oxidized in the tricyclic acid (TCA) cycle and improves physical endurance in athletes. Our primary objective is to test if KE boosts muscular ATP homeostasis in VLCADD patients to establish a rational basis for therapeutic use.
VLCADD patients will be included in a randomized, blinded, placebo controlled, 2-way cross-over trial. Prior to each test, patients receive a KE drink or an isocaloric carbohydrate equivalent, and completed a 35 min cycling test on an upright bicycle, followed by 10 minutes of supine cycling inside a MR scanner. The protocol will be repeated after at least one week with the opposite drink.
Study Design
Arms and Interventions
| Arm | Intervention/Treatment |
|---|---|
| Experimental: ketone ester drink Oral intake of ketone ester drink muscle biopsy exercise muscle biopsy Magnetic Resonance imaging |
Dietary Supplement: ketone ester drink
395 mg of ketone ester/kg
Other Names:
Behavioral: exercise
35 min cycling test on an upright bicycle, followed by 10 minutes of supine cycling inside a MR scanner.
Procedure: muscle biopsy
biopsy from the quadriceps muscle prior to and immediately after upright bicycling
Diagnostic Test: Magnetic Resonance Imaging
1H MR images and 31P MR spectra were acquired from the upper leg prior to-, during and after exercise
Other Names:
|
| Placebo Comparator: carbohydrate drink Oral intake of isocaloric carbohydrate drinkmuscle biopsy exercise muscle biopsy Magnetic Resonance imaging |
Behavioral: exercise
35 min cycling test on an upright bicycle, followed by 10 minutes of supine cycling inside a MR scanner.
Procedure: muscle biopsy
biopsy from the quadriceps muscle prior to and immediately after upright bicycling
Diagnostic Test: Magnetic Resonance Imaging
1H MR images and 31P MR spectra were acquired from the upper leg prior to-, during and after exercise
Other Names:
|
Outcome Measures
Primary Outcome Measures
- Change of ATP concentration in millimolar [During session 2 and 3: continuous measurements from t=75 minutes until t=85 minutes]
steady-state in vivo intramuscular concentration of ATP metabolites during rest and exercise.
- Change of PCr concentration in millimolar [During session 2 and 3: continuous measurements from t=75 minutes until t=85 minutes]
steady-state in vivo intramuscular concentration of ATP metabolites during rest and exercise.
- Change of Pi concentration in millimolar [During session 2 and 3: continuous measurements from t=75 minutes until t=85 minutes]
steady-state in vivo intramuscular concentration of ATP metabolites during rest and exercise.
Secondary Outcome Measures
- kinetic rate constant of ATP synthesis in Hertz [session 2 and 3, 10 minutes each time]
rate constant of Pi and PCr recovery post-exercise
- intramuscular concentration of H+ in millimolar [session 2 and 3, 10 minutes each time]
steady-state in vivo intramuscular concentration of H+ during rest and exercise
- completion of 35 minute upright bicycling bout at FATMAX [Session 2 and 3, 35 minutes]
(yes/no; if no, #minutes)
- completion of 10 minute supine bicycling bout at FATMAX in scanner [Session 2 and 3, 10 minutes]
(yes/no; if no, #minutes)
- HR in beats per minute [During session 1, 15 minutes During Session 2 + 3: 35 minutes]
heart rate, VO2 and VCO2 dynamics. During session 2+3 breath sampling will be done for 2 minutes per timepoint, simultaneously with blood sampling.
- VO2 in milliliter per minute per kilogram [During session 1, 15 minutes During Session 2 + 3: 35 minutes]
heart rate, VO2 and VCO2 dynamics. During session 2+3 breath sampling will be done for 2 minutes per timepoint, simultaneously with blood sampling.
- VCO2 in milliliter per minute per kilogram [During session 1, 15 minutes During Session 2 + 3: 35 minutes]
VCO2 dynamics during session 2+3 breath sampling for 2 minutes per timepoint, simultaneously with blood sampling.
- Changes in blood metabolites: D-betahydroxybutyrate in millimol per liter [Session 2 and 3, 265 minutes per session]
Samples are taken at baseline, 30 minutes, 40 minutes, 50 minutes, 60 minutes, 75 minutes, 85 minutes and 265 minutes after ingestion of the testdrink
- Changes in blood metabolites: glucose in millimol per liter [Session 2 and 3, 265 minutes per session]
Samples are taken at baseline, 30 minutes, 40 minutes, 50 minutes, 60 minutes, 75 minutes, 85 minutes and 265 min after ingestion of the testdrink
- Changes in blood metabolites: lactate in millimol per liter [Session 2 and 3, 265 minutes per session]
Samples are taken at baseline, 30 minutes, 60 minutes, 85 minutes and 265 min after ingestion of the testdrink
- Changes in blood metabolites: insulin in picomol per liter [Session 2 and 3, 265 minutes per session]
Samples are taken at baseline, 30 minutes, 60 minutes, 85 minutes and 265 min after ingestion of the testdrink
- Changes in blood metabolites: creatine kinase in units per liter [Session 2 and 3, 265 minutes per session]
Samples are taken at baseline, 30 minutes, 60 minutes, 85 minutes and 265 min after ingestion of the testdrink
- Changes in blood metabolites: triglycerides in millimol per liter [Session 2 and 3, 265 minutes per session]
Samples are taken at baseline, 30 minutes, 60 minutes, 85 minutes and 265 min after ingestion of the testdrink
- Changes in blood metabolites: LDL cholesterol in millimol per liter [Session 2 and 3, 265 minutes per session]
Samples are taken at baseline, 30 minutes, 60 minutes, 85 minutes and 265 min after ingestion of the testdrink
- Changes in blood metabolites: free fatty acids in millimol per liter [Session 2 and 3, 265 minutes per session]
Samples are taken at baseline, 30 minutes, 40 minutes, 50 minutes, 60 minutes, 75 minutes, 85 minutes and 265 min after ingestion of the test drink
- Changes in blood metabolites: total cholesterol in millimol per liter [Session 2 and 3, 265 minutes per session]
Samples are taken at baseline, 30 minutes, 60 minutes, 85 minutes and 265 min after ingestion of the testdrink
- Changes in blood metabolites: HDL cholesterol in millimol per liter [Session 2 and 3, 265 minutes per session]
Samples are taken at baseline, 30 minutes, 60 minutes, 85 minutes and 265 min after ingestion of the testdrink
- Changes in blood metabolites: acylcarnitines in micromol per liter [Session 2 and 3, 265 minutes per session]
Samples are taken at baseline, 30 minutes, 40 minutes, 50 minutes, 60 minutes, 75 minutes, 85 minutes and 265 min after ingestion of the test drink
- Subjective exertion [During Session 2 + 3, assessed during blood sampling, 265 minutes per session]
Measured with Borg score (range from 6 (rest) to 20 (extreme exertion)).
- height in meters [1 minute during screening visit]
height of patient
- weight in kilogram [1 minute during screening visit]
weight of patient to dose intervention and normalize outcome parameters
- BMI in kg/m^2 [1 minute during screening visit]
weight and height will be combined to report BMI in kg/m^2
- optional: TCA intermediates in muscle tissue (units is ratio of metabolite peak/ internal standard) and will be expressed as fold change from baseline [Session 2+3: before and after exercise, 20 minutes per session]
metabolomics (mass spectrometry) of muscle tissue on a voluntary basis
- optional: glycolysis intermediates in muscle tissue (units is ratio of metabolite peak/ internal standard) and will be expressed as fold change from baseline [Session 2+3: before and after exercise, 20 minutes per session]
metabolomics (mass spectrometry) of muscle tissue on a voluntary basis
- optional: acylcarnitines in muscle tissue (units is ratio of metabolite peak/ internal standard) and will be expressed as fold change from baseline [Session 2+3: before and after exercise, 20 minutes per session]
metabolomics (mass spectrometry) of muscle tissue on a voluntary basis
- optional: D-betahydroxybutyrate in muscle tissue (units is ratio of metabolite peak/ internal standard) and will be expressed as fold change from baseline [Session 2+3: before and after exercise, 20 minutes per session]
metabolomics (mass spectrometry) of muscle tissue on a voluntary basis
- optional: capillary density in muscle tissue based on CD31 staining (capillaries per millimeter^2) [Session 2+3: before and after exercise, 20 minutes per session]
individual phenotypic muscle properties on a voluntary basis. Immunohistochemistry.
- optional: mitochondrial density based on ATPase, COX-SDH, SDH and NADH staining (intensity per microgram per minute). [Session 2+3: before and after exercise, 20 minutes per session]
individual phenotypic muscle properties on a voluntary basis. Immunohistochemistry.
- optional: mitochondrial density based on as citrate synthase activity expressed as absorbance/s/mg. [Session 2+3: before and after exercise, 20 minutes per session]
individual phenotypic muscle properties on a voluntary basis.
- optional: parameters for metabolism and mitochondrial function in muscle (AMPK, PPAR gamma, PGC1a, and GLUT4). All expressed as protein content as % of control. [Session 2+3: before and after exercise, 20 minutes per session]
individual phenotypic muscle properties on a voluntary basis. Westernblots.
- optional: lipid accumulation based on Oil-Red-O staining (intensity of staining, and percentage positive-stained cells). [Session 2+3: before and after exercise, 20 minutes per session]
individual phenotypic muscle properties on a voluntary basis. Immunohistochemistry.
- optional: muscle fiber type composition based on myosin heavy chain profiling. Type I, IIa, IIx fibres will be expressed as % of total fibres. [Session 2+3: before and after exercise, 20 minutes per session]
individual phenotypic muscle properties on a voluntary basis.
- optional: muscle fiber type composition based on ATPase staining (intensity/ug/min). Type I, IIa, IIx fibres will be expressed as % of total fibres. [Session 2+3: before and after exercise, 20 minutes per session]
individual phenotypic muscle properties on a voluntary basis. Immunohistochemistry.
- optional: glycogen content of muscle based on Periodic acid-Schiff (PAS) staining (intensity per millimeter^2) [Session 2+3: before and after exercise, 20 minutes per session]
individual phenotypic muscle properties on a voluntary basis. Immunohistochemistry.
- optional: glycogen content of muscle measured as glucose released after enzymatic digestion with amyloglucosidase expressed as micromol per gram wet muscle weight. [Session 2+3: before and after exercise, 20 minutes per session]
individual phenotypic muscle properties on a voluntary basis.
Eligibility Criteria
Criteria
Inclusion Criteria:
- Confirmed VLCADD by genetic profiling
Exclusion Criteria:
-
contraindications for MRI studies (assessed by standardised questionnaire as previously used in METC 08-267/K; see UMCG section F METC documents)
-
inability to perform bicycle exercise.
-
recent episode of rhabdomyolysis, or treatment for acute renal failure in the past 2 months.
-
intercurrent illness which may influence exercise tolerance (anaemia, musculoskeletal injury, or other undiagnosed illness under investigation).
-
known coronary artery disease, positive history for angina, or changes on ECG suggestive of previous ischaemia without a negative stress test.
-
insulin-dependent diabetes mellitus.
-
loss of, or an inability to give informed consent.
-
pregnancy or current breastfeeding, or females not taking the oral contraceptive pill (this is due to the variability in hormonal patterns and substrate levels with different parts of the menstrual cycle).
-
any other cause which in the opinion of the investigators, may affect the volunteers ability to participate in the study.
Contacts and Locations
Locations
| Site | City | State | Country | Postal Code | |
|---|---|---|---|---|---|
| 1 | Academic Medical Center | Amsterdam | Noord-Holland | Netherlands | 1105 AZ |
| 2 | Dept of Neuroscience/ Neuroimaging Center | Groningen | Netherlands | 9700RB |
Sponsors and Collaborators
- University Medical Center Groningen
- UMC Utrecht
- Academisch Medisch Centrum - Universiteit van Amsterdam (AMC-UvA)
- University of Oxford
- ESN (Erfelijke Stofwisselingsziekten Nederland)
Investigators
- Principal Investigator: Jeroen AL Jeneson, PhD, Dept of Neuroscience/ Neuroimaging Center Groningen
Study Documents (Full-Text)
More Information
Publications
- Cox PJ, Kirk T, Ashmore T, Willerton K, Evans R, Smith A, Murray AJ, Stubbs B, West J, McLure SW, King MT, Dodd MS, Holloway C, Neubauer S, Drawer S, Veech RL, Griffin JL, Clarke K. Nutritional Ketosis Alters Fuel Preference and Thereby Endurance Performance in Athletes. Cell Metab. 2016 Aug 9;24(2):256-68. doi: 10.1016/j.cmet.2016.07.010. Epub 2016 Jul 27.
- Diekman EF, Visser G, Schmitz JP, Nievelstein RA, de Sain-van der Velden M, Wardrop M, Van der Pol WL, Houten SM, van Riel NA, Takken T, Jeneson JA. Altered Energetics of Exercise Explain Risk of Rhabdomyolysis in Very Long-Chain Acyl-CoA Dehydrogenase Deficiency. PLoS One. 2016 Feb 16;11(2):e0147818. doi: 10.1371/journal.pone.0147818. eCollection 2016.
- METC2014.492;ABR51222.042.14