314例单纯型甲基丙二酸血症的临床表型和基因型研究

The phenotypes and genotypes in 314 patients with isolated methylmalonic acidemia

目的总结单纯型甲基丙二酸血症的临床表型及分子遗传学特点,探讨诊断、治疗及预防对策。方法回顾性收集我国26个省市1998年1月至2020年3月确诊的单纯型甲基丙二酸血症患儿314例(男180例、女134例),采用Sanger测序、靶向捕获二代测序或者全外显子测序分析、多重连接依赖探针扩增技术、定量PCR等技术进行基因诊断。根据发病年龄,分为早发型(发病年龄≤12月龄)和晚发型(发病年龄>12月龄)。根据个体情况,给予钴胺素、左卡尼汀、特殊饮食及对症治疗。采用χ2检验进行组间比较。结果314例单纯型甲基丙二酸血症患儿中58例(18.5%)通过液相串联质谱法新生儿筛查发现,5例(1.6%)为尸检确诊,251例(79.9%)患儿为发病后临床诊断。发病年龄为3小时龄~18岁,其中早发型159例(71.0%),晚发型65例(29.0%)。较常见的临床表现是代谢危象、智力运动落后、癫痫、贫血和多脏器损伤。早发型较晚发型患儿代谢性酸中毒及贫血常见[20.8%(33/159)比9.2%(6/65),34.6%(55/159)比16.9%(11/65),χ^2=4.261、6.930,P=0.039、0.008]。236例(75.2%)接受了基因分析,227例(96.2%)获得了基因诊断,在7个基因(MMUT、MMAA、MMAB、MMADHC、SUCLG1、SUCLA2、MCEE)上共发现127个变异,其中49个为新变异。MMUT变异导致的甲基丙二酰辅酶A变位酶缺乏(mut型)211例(93.0%),常见的MMUT变异是c.729_730insTT、c.1106G>A、c.914T>C。c.914T>C在早发型中发生的频率较晚发型高[8.3%(18/216)比1.6%(1/64),χ^2=3.859,P=0.037]。mut型较其他类型患儿代谢危象常见[72.6%(114/157)比3/13,χ^2=13.729,P=0.001]。发育落后、肌张力低下在mut型患儿中比其他类型患儿少见[38.2%(60/157)比9/13、25.5%(40/157)比8/13,χ^2=4.789、7.705,P=0.030、0.006]。58例新生儿筛查发现的患儿中44例(75.9%)从无症状时开始治疗,发育正常;14例(24.1%)临床发病后才开始接受治疗,遗留有不同程度的智力、运动发育落后。结论分析了我国单纯型甲基丙二酸血症患儿的临床表型与基因型特点及相关性,扩展了基因变异谱。鉴于单纯型甲基丙二酸血症有临床表现复杂及早发严重的倾向,新生儿筛查对于早期诊断、改善预后至关重要。建议将致病基因MMUT列入我国育龄夫妇孕前携带者筛查目录中,关口前移至出生缺陷一级预防。

Objectives To summarize the clinical and genetic characteristics of the patients with isolated methylmalonic acidemia and investigate the strategies for the diagnosis,treatment and prevention.Methods Three hundred and fourteen patients(180 males,134 females)with isolated methylmalonic acidemia were ascertained from 26 provinces or cities across the mainland of China during January 1998 to March 2020.Genetic analysis was performed by Sanger sequencing,gene panel sequencing,whole exome sequencing,multiplex ligation-dependent probe amplification or quantitative PCR.According to the age of onset,the patients were divided to early-onset group(≤12 months of age)and the late-onset group(>12 months of age).They were treated by cobalamin,L-carnitine and(or)special diet and symptomatic treatment.Statistical analysis was done using Chi-square test.Results Fifty-eight of 314(18.5%)patients were detected by Newborn screening using liquid chromatography tandem mass spectrometry.Five cases(1.6%)had a postmortem diagnosis.Two hundred and fifty-one patients(79.9%)were clinically diagnosed with an age of onset ranged from 3 hours after birth to 18 years.One hundred and fifty-nine patients(71.0%)belonged to early-onset groups,65 patients(29.0%)belonged to the late-onset group.The most common symptoms were metabolic crises,psychomotor retardation,epilepsy,anemia and multiple organ damage.Metabolic acidosis and anemia were more common in early-onset patients than that in late-onset patients(20.8%(33/159)vs.9.2%(6/65),34.6%(55/159)vs.16.9%(11/165),χ2=4.261,6.930,P=0.039,0.008).Genetic tests were performed for 236 patients(75.2%),96.2%(227/236)had molecular confirmation.One hundred and twenty-seven variants were identified in seven genes(MMUT,MMAA,MMAB,MMADHC,SUCLG1,SUCLA2,and MCEE),of which 49 were novel.The mut type,caused by the deficiency of methylmalonyl-CoA mutase,was the most common(n=211,93%)cause of this condition.c.729_730insTT,c.1106G>A and c.914T>C were the three most frequent mutations in MMUT gene.The frequency of c.914T>C in early-onset patients was significantly higher than that in late-onset patients(8.3%(18/216)vs.1.6%(1/64),χ^2=3.859,P=0.037).Metabolic crisis was more frequent in mut type than the other types(72.6%(114/157)vs.3/13,χ^2=13.729,P=0.001),developmental delay and hypotonia were less frequent in mut type(38.2%(60/157)vs.9/13,25.5%(40/157)vs.8/13,χ^2=4.789,7.705,P=0.030,0.006).Of the 58 patients identified by newborn screening,44 patients(75.9%)who were treated from asymptomatic phase developed normally whereas 14 patients(24.1%)who received treatment after developing symptoms exhibited varying degrees of psychomotor retardation.Conclusions The characteristics of phenotypes and genotypes among Chinese patients with isolated methylmalonic acidemia were analyzed.Expanded the mutation spectrum of the associated genes.Because of the complex clinical manifestations and severe early onset of isolated methylmalonic acidemia,Newborn screening is crucial for early diagnosis and improvement of prognosis.MMUT gene is recommended for carrier screening as an effort to move the test earlier as a part of the primary prevention of birth defects.