Untargeted metabolomics and infrared ion spectroscopy identify biomarkers for pyridoxine-dependent epilepsy

Udo Fg Engelke, Rianne E van Outersterp, Jona Merx, Fred Amg van Geenen, Arno van Rooij, Giel Berden, Marleen Cdg Huigen, Leo Aj Kluijtmans, Tessa Ma Peters, Hilal H Al-Shekaili, Blair R Leavitt, Erik de Vrieze, Sanne Broekman, Erwin van Wijk, Laura A Tseng, Purva Kulkarni, Floris Pjt Rutjes, Jasmin Mecinović, Eduard A Struys, Laura A JansenSidney M Gospe, Saadet Mercimek-Andrews, Keith Hyland, Michel Aap Willemsen, Levinus A Bok, Clara Dm Van Karnebeek, Ron A Wevers, Thomas J Boltje, Jos Oomens, Jonathan Martens, Karlien Lm Coene

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Background. Pyridoxine-dependent epilepsy (PDE-ALDH7A1) is an inborn error of lysine catabolism that presents with refractory epilepsy in newborns. Biallelic ALDH7A1 variants lead to deficiency of α-aminoadipic semialdehyde dehydrogenase/ antiquitin, resulting in accumulation of piperideine-6-carboxylate (P6C), and secondary deficiency of the important cofactor pyridoxal-5′-phosphate (PLP, active vitamin B6) through its complexation with P6C. Vitamin B6 supplementation resolves epilepsy in patients, but intellectual disability may still develop. Early diagnosis and treatment, preferably based on newborn screening, could optimize long-term clinical outcome. However, no suitable PDE-ALDH7A1 newborn screening biomarkers are currently available. Methods. We combined the innovative analytical methods untargeted metabolomics and infrared ion spectroscopy to discover and identify biomarkers in plasma that would allow for PDE-ALDH7A1 diagnosis in newborn screening. Results. We identified 2S,6S-/2S,6R-oxopropylpiperidine-2-carboxylic acid (2-OPP) as a PDE-ALDH7A1 biomarker, and confirmed 6-oxopiperidine-2-carboxylic acid (6-oxoPIP) as a biomarker. The suitability of 2-OPP as a potential PDE-ALDH7A1 newborn screening biomarker in dried bloodspots was shown. Additionally, we found that 2-OPP accumulates in brain tissue of patients and Aldh7a1-knockout mice, and induced epilepsy-like behavior in a zebrafish model system. Conclusion. This study has opened the way to newborn screening for PDE-ALDH7A1. We speculate that 2-OPP may contribute to ongoing neurotoxicity, also in treated PDE-ALDH7A1 patients. As 2-OPP formation appears to increase upon ketosis, we emphasize the importance of avoiding catabolism in PDE-ALDH7A1 patients.

Original languageEnglish
Article numbere148272
JournalJournal of Clinical Investigation
Issue number15
Number of pages16
Publication statusPublished - Aug 2021


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