Objective: Argininosuccinate lyase (ASL) is integral to the urea cycle, which enables nitrogen wasting and biosynthesis of arginine, a precursor of nitric oxide.Inherited ASL deficiency causes argininosuccinic aciduria, the second most common urea cycle defect and an inherited model of systemic nitric oxide deficiency.Patients present with developmental delay, epilepsy, and movement disorder.Here we aim to characterize epilepsy, a common and neurodebilitating comorbidity in argininosuccinic aciduria.
Methods:We conducted a retrospective study in seven tertiary metabolic centers in the UK, Italy, and Canada from 2020 to 2022, to assess the phenotype of | 1613 ELKHATEEB et al.
| INTRODUCTIONArgininosuccinate lyase (ASL) is the only enzyme in mammals enabling endogenous arginine synthesis. 1 This cytosolic enzyme, which breaks down argininosuccinic acid into arginine and fumarate, is integral to the citrulline-nitric oxide (NO) cycle, which enables NO synthesis from arginine, and the urea cycle, a liver-based pathway enabling nitrogen wasting through clearance of neurotoxic ammonia. 1 ASL deficiency causes argininosuccinic aciduria (ASA) (OMIM#207900), an autosomal recessive metabolic disease and the second most common urea cycle disorder with a prevalence of one in 110 000 live births. 2 Patients present acute hyperammonemia either in the neonatal period defined as early-onset phenotype, or later in life in late-onset presentation. 3 Most patients will present a multisystemic phenotype with chronic neurological, hepatic, and gastrointestinal conditions, and anemia and high blood pressure. 4 The neurological phenotype entails intellectual and motor disability, behavioral changes, and epilepsy, which can occur in the absence epilepsy in argininosuccinic aciduria and correlate it with clinical, biochemical, radiological, and electroencephalographic data.Results: Thirty-seven patients, 1-31 years of age, were included. Twenty-two patients (60%) presented with epilepsy. The median age at epilepsy onset was 24 months. Generalized tonic-clonic and focal seizures were most common in early-onset patients, whereas atypical absences were predominant in late-onset patients. Seventeen patients (77%) required antiseizure medications and six (27%) had pharmacoresistant epilepsy. Patients with epilepsy presented with a severe neurodebilitating disease with higher rates of speech delay (p = .04) and autism spectrum disorders (p = .01) and more frequent arginine supplementation (p = .01) compared to patients without epilepsy. Neonatal seizures were not associated with a higher risk of developing epilepsy. Biomarkers of ureagenesis did not differ between epileptic and non-epileptic patients. Epilepsy onset in early infancy (p = .05) and electroencephalographic background asymmetry (p = .0007) were significant predictors of partially controlled or refractory epilepsy.Significance: Epilepsy in argininosuccinic aciduria is frequent, polymorphic, and associated with more frequent neurodevelopmental comorbidities. We identified prognostic...