Maple syrup urine disease (MSUD) is a rare, inherited metabolic disorder that affects the body's ability to metabolize amino acids due to a deficiency in the activity of the branched-chain alpha-ketoacid dehydrogenase (BCKAD) complex. It particularly affects the metabolism of amino acids leucine, isoleucine, and valine. With MSUD, the body is not able to properly break down these amino acids, therefore leading to the amino acids to build up in urine and become toxic. The condition gets its name from the distinctive sweet odor of affected infants' urine and earwax due to the buildup of these amino acids.

Classification

Maple syrup urine disease can be classified by its pattern of signs and symptoms or by its genetic cause. The most common and severe form of this disease is the classic type, which appears soon after birth, and as long as it remains untreated, gives rise to progressive and unremitting symptoms. Variant forms of the disorder may become apparent only later in infancy or childhood, with typically less severe symptoms that may only appear during times of fasting, stress, or illness, but still involve mental and physical problems if left untreated.

There are five main types of maple syrup urine disease:

  • Classic maple syrup urine disease
  • Intermediate maple syrup urine disease
  • Intermittent maple syrup urine disease
  • Thiamine-responsive maple syrup urine disease
  • E3-deficient maple syrup urine disease

These types can be classified based on time of onset, severity of symptoms, and level of BCKAD complex enzyme activity. Symptoms can be seen from within 7–10 days of birth. The maple syrup odor to the earwax is apparent around 12 hours after birth. The sweet-smelling urine is presented around a week after birth when protein metabolism has accelerated.

Infants with classic MSUD will display subtle symptoms within the first 24–48 hours. Subtle symptoms include poor feeding, either bottle or breast, lethargy, and irritability. The infant will then experience increased focal neurologic signs. These neurologic signs include athetosis, hypertonia, spasticity, and opisthotonus that lead to convulsions and coma. If MSUD is left untreated, central neurologic function and respiratory failure will occur and lead to death. Although MSUD can be stabilized, there are still threats of metabolic decompensation and loss of bone mass that can lead to osteoporosis, pancreatitis, and intracranial hypertension. Additional signs and symptoms that can be associated with classic MSUD include intellectual limitation and behavioral issues.

Intermediate

This type is a milder form of MSUD in comparison to classic MSUD. anemia, diarrhea, vomiting, dehydration, lethargy, Some characteristics of MSUD include maple syrup odor to the urine or earwax, neurological disorders, psychological disorders, feeding problems, and metabolic acidosis. If left untreated, it may lead to metabolic crisis. Metabolic crises can be life-threatening and should be treated immediately. The buildup of these BCAAs will lead to the maple syrup odor in earwax and urine that is associated with MSUD. The BCKAD complex begins by breaking down leucine, isoleucine, and valine through the use of branch-chain aminotransferase (BCAT) into their relevant α-ketoacids. The second step involves the conversion of α-ketoacids into acetoacetate, acetyl-CoA, and succinyl-CoA through oxidative decarboxylation of α-ketoacids. The BCKAD complex consists of four subunits designated E<sub>1</sub>α, E<sub>1</sub>β, E<sub>2</sub>, and E<sub>3</sub>. The E<sub>3</sub> subunit is also a component of pyruvate dehydrogenase complex and oxoglutarate dehydrogenase complex. MSUD can result from mutations in any of the genes that code for these enzyme subunits, E<sub>1</sub>α, E<sub>1</sub>β, E<sub>2</sub>, and E<sub>3</sub>.

In a normal physiological state, large neutral amino acids (LNAA) are transferred from the blood to the brain via the large amino acid transporter (LAT1/SLC7A5) at the blood-brain barrier. However, increased plasma levels and higher affinity of leucine may saturate LAT1, thereby competitively preventing the transportation of other amino acids, resulting in lower concentrations within the brain.

Neurotoxicity

Neurotoxic effects have been observed in experimental studies linking the accumulation of BCAA and BCKA to the neuropathology seen in individuals with MSUD. Recent review articles have expanded on the neurotoxicity associated with MSUD, highlighting its contribution to changes in cellular bioenergetics (via disruption of the citric acid cycle in mitochondria), oxidative stress, and pro-inflammatory states. Changes have been observed in various markers related to each respective state. For cellular bioenergetics, changes include lactate levels, creatine levels, NAD+/NADH ratio (nicotinamide adenine dinucleotide), ATP (adenosine triphosphate) and pyruvate concentrations, mitochondrial complex activity, and CK (creatine kinase) activity. In oxidative stress, changes are seen in GSH (glutathione), MDA (malondialdehyde), TAR (total antioxidant response), nitric oxide, DNA oxidative damage levels, and the enzymatic activity of GPS (glutathione peroxidase), GR (glutathione reductase), CAT (catalase), and SOD (superoxide dismutase). For the pro-inflammatory state, biomarker changes are seen in IL-6 (interleukin-6), IL-10 (interleukin-10), IL-1beta (interleukin-1 beta), TNF-gamma (tumor necrosis factor-gamma), TNF-alpha (tumor necrosis factor-alpha), sICAM-1 (soluble intercellular adhesion molecule-1), sVCAM-1 (soluble vascular cell adhesion molecule-1), and cathepsin levels. These neurotoxic changes have been linked to the activation of neuronal apoptotic pathways, leading to cell death and morphological changes in the brain.

Newborn screening

On May 9, 2014, the UK National Screening Committee (UK NSC) announced its recommendation to screen every newborn baby in the UK for four further genetic disorders as part of its NHS Newborn Blood Spot Screening programme, including maple syrup urine disease. The disease is estimated to affect 1 out of 185,000 infants worldwide and its frequency increases with certain heritages.

Classification

MSUD has five clinical phenotypes that are very distinct from one another. The most common and severe is the classical type with low residual activity from 0–2% of normal. Milder types include intermediate and intermittent with higher residual activities from 3–30% of the normal. Most unique is the thiamine-responsive type, where patients respond to high doses of thiamine administered, although this method is controversial. Lastly, the E-3 deficient type is correlated to combined enzyme deficiencies in pyruvate dehydrogenase, BCKD complexes, and alpha-ketoglutarate dehydrogenase, since E3 is common within mitochondrial alpha-ketoacid dehydrogenase complexes.

NBS (newborn screening) detects most individuals with intermediate MSUD, but those who were not screened as newborns can be later diagnosed with MSUD. In these individuals, plasma BCAA concentrations are similar to those who have classic MSUD. However, they have better Lucine tolerance, and during acute metabolic decompensation episodes, they do not require intensive nutritional support. Severe metabolic intoxication with significant encephalopathy and leucinosis can occur if subjected to serious catabolic stress.

Prevention

There are no methods for preventing the manifestation of the pathology of MSUD in infants with two defective copies of the BCKD gene. However, genetic counselors may consult with couples to screen for the disease via DNA testing. DNA testing is also available to identify the disease in an unborn child in the womb.

Treatment

Monitoring

Keeping MSUD under control requires careful monitoring of blood chemistry, both at home and in a hospital setting. DNPH or specialized dipsticks may be used to test the patient's urine for ketones (a sign of metabolic decompensation), when metabolic stress is likely or suspected. Fingerstick tests are performed regularly and sent to a laboratory to determine blood levels of leucine, isoleucine, and valine. Regular metabolic consultations, including blood draws for full nutritional analysis, are recommended; especially during puberty and periods of rapid growth. MSUD management also involves a specially tailored metabolic formula, a modified diet, and lifestyle precautions such as avoiding fatigue and infections, as well as consuming regular, sufficient calories in proportion to physical stress and exertion. Without sufficient calories, catabolism of muscle protein will result in a metabolic crisis. Those with MSUD must be hospitalized for intravenous infusion of sugars and nasogastric drip-feeding of formula, in the event of metabolic decompensation, or lack of appetite, diarrhea or vomiting. Food avoidance, rejection of formula, and picky eating are all common problems with MSUD. Some patients may need to receive all or part of their daily nutrition through a feeding tube.

Appropriate Branched-Chain Amino Acid (BCAA) blood concentrations:

LEU plasma concentrations for infants and children 5 years old and younger should be between 75-200&nbsp;mmol/L. For anyone 5 years or older LEU plasma concentrations should maintain between 75-300&nbsp;mmol/L to maintain mental status. LEU is key for protein synthesis involved with growth, repair, and health maintenance.

ILE and VAL plasma concentrations should ideally be between 200-400&nbsp;mmol/L to maintain metabolic balance and avoid BCAA deficits. Isoleucine and Valine help promote anabolism which decreases plasma Leucine concentrations.

Toxin removal

Following diagnosis, rapid removal of excess leucine from the body reduces the impact of the disease on development. Some methods of toxin removal include Exchange transfusion, hemodialysis, or hemofiltration. Exchange transfusion is an option to consider because it decreases high BCAA levels without disrupting the plasma repeatedly, however after exchange the BCAA levels will increase with the tissue storage releasing BCAAs. Hemodialysis is a safe and effective way to reduce elevated BCAA levels while correcting electrolyte and acid-base imbalances in an infant. Hemodialysis can be started as soon as a diagnosis is made when it is combined with dietary feeds that maintain recommended calorie and amino acid intake.

Diet control

A diet with carefully controlled levels of the amino acids leucine, isoleucine, and valine must be maintained at all times to reduce toxic metabolites to prevent neurological damage. Since these three amino acids occur in all-natural protein, and most natural foods contain some protein, any food intake must be closely monitored, and day-to-day protein intake calculated on a cumulative basis, to ensure individual tolerance levels are not exceeded at any time. As the MSUD diet is so protein-restricted, and adequate protein is a requirement for all humans, a tailored metabolic formula containing all the other essential amino acids, as well as any vitamins, minerals, omega-3 fatty acids and trace elements (which may be lacking due to the limited range of permissible foods), are an essential aspect of MSUD management. These complement the MSUD patient's natural food intake to meet normal nutritional requirements without causing harm. If adequate calories cannot be obtained from natural food without exceeding protein tolerance, specialized low protein products such as starch-based baking mixtures, imitation rice and pasta may be prescribed, often alongside a protein-free carbohydrate powder added to food and/or drink, and increased at times of metabolic stress. MSUD patients with thiamine-responsive MSUD can have a higher protein intake diet with the administration of high doses of thiamine, a cofactor of the enzyme that causes the condition. The typical dosage amount of thiamine-responsive MSUD depends on the enzyme activity present and can range from 10&nbsp;mg - 100&nbsp;mg daily.

Acute Metabolic Decompensation

When Leucine plasma levels elevate due to not following the strict MSUD diets, infection, or physiological stress this may induce acute metabolic decompensation. Individuals with lower residual BCKAD activity have increased risk. Typically Leucine levels >380&nbsp;mmol/L will lead to metabolic decompensation. The goal in treating acute decompensation is to stop protein breakdown and increase protein synthesis. This procedure is most successful when performed at a young age, and weaning from immunosuppressants may even be possible in the long run. However, the surgery is a major undertaking requiring extensive hospitalization and rigorous adherence to a tapering regimen of medications. Following transplant, the risk of periodic rejection will always exist, as will the need for some degree of lifelong monitoring in this respect. Despite normalizing clinical presentation, liver transplantation is not considered a cure for MSUD. The patient will still carry two copies of the mutated BKAD gene in each of their cells, which will consequently still be unable to produce the missing enzyme. They will also still pass one mutated copy of the gene on to each of their biological children. As a major surgery, the transplant procedure itself also carries standard risks, although the odds of its success are greatly elevated when the only indication for it is an inborn error of metabolism. In the absence of a liver transplant, the MSUD diet must be adhered to strictly and permanently. However, in both treatment scenarios, with proper management, those affected can live healthy, normal lives without experiencing the severe neurological damage associated with the disease.

Pregnancy

Control of metabolism is vital during pregnancy of women with MSUD. To prevent detrimental abnormalities in the development of the embryo or fetus, dietary adjustments should be made and plasma amino acid concentrations of the mother should be observed carefully and frequently. Amino acid deficiency can be detected through fetal growth, making it essential to monitor development closely.

Prognosis

There are risks of long-term neurological effects from maple syrup urine disease. These may include ADHD, anxiety, depression, etc. Early diagnosis can improve cognitive development, but the effects are largely dependent on the quality of healthcare systems and disease type. Cognitive development may be shown to be below that of the general population. The severity of the cognitive delay is related to the time the condition remained undiagnosed and the effectiveness of dietary control including during metabolic crises.

Maple syrup urine disease is classified as an autosomal recessive disorder and has a higher prevalence in populations that have higher consanguinity. Infants who are not treated for early onset MSUD experience a significant delay in development and usually die within a few months of birth. Younger children with late-onset MSUD may experience developmental delay also, depending on the enzyme activity of BKCD (branched-chain alpha-keto acid dehydrogenase). In children with periods of increased protein catabolism, there is an increased risk for metabolic decompensation. Early diagnosis can prevent morbidity in most cases as long as correct treatment is administered at presentation and periods of possible metabolic decompensation. MSUD occurs in all ethnic groups and the sex of the infant/child does not play a role in prevalence.

NBS (newborn screening) programs incorporate MSUD screening in the United States, five provinces in Canada, Twenty-two European countries, eight Asian Pacific countries, and two Latin American countries.

Phenylbutyrate therapy

Sodium phenylacetate/benzoate or sodium phenylbutyrate has been shown to reduce BCAA in a clinical trial done February 2011. Phenylbutyrate treatment reduced the blood concentration of BCAA and their corresponding BCKA in certain groups of MSUD patients and may be a possible adjunctive treatment.

Metformin therapy

Metformin, a drug used for weight loss in diabetes patients, has been shown to reduce keto-isoaproic acid (KIC) in patient-derived fibroblasts as well as a murine model of MSUD. Metformin has also been shown to aid weight loss in MSUD patients who are at increased risk for obesity and related complications when following prescribed hyper-caloric diets to avoid metabolic decompensation.

Minocycline Therapy

Minocycline has been shown to reduce oxidative stress in a model of MSUD; results suggest that minocycline may have a neuro-protective role in MSUD.

Therapeutics for neurotoxicity

Exploring targeted therapeutics for the various states contributing to neurotoxicity may play a role in treating individuals with MSUD.