“…In support of our findings, increased CK, low carnitine, slightly increased acyl-carnitines, increased TCA cycle metabolites and accumulation of lipids, glycogen and abnormal mitochondria have been reported previously in RIRCD patients (Boczonadi et al, 2015). FGF21 has been recently described to drive the integrated mitochondrial stress response and activate a cascade of events in mitochondrial myopathy patients and mice, thus leading to a distinct metabolic remodelling (AlJohani, Khan et al, 2019, Forsstrom et al, 2019, Lehtonen, Forsstrom et al, 2016, von Holstein-Rathlou, BonDurant et al, 2016). Here we show, that FGF21 is associated with the activation of an integrated stress response (increased GCN2, phospho EIF2α, ATF4 and ATF5) (Pakos-Zebrucka, Koryga et al, 2016) in RIRCD, concomitant with an increase in fatty acid oxidation and TCA cycle associated enzymes, thus, leading to an alternative energy source (bypassing complex IV and V) which, most likely to compensate for the lack of ATP.…”