Case of YK

HPI
Y is an 8-year-old Japanese female who presented
with a known diagnosis to our genetics clinic.

She was born at 39 weeks via C-section for failure to

progress. Her mother was induced secondary to
IUGR and oligohydramnios. She weighed 2416g (<3 rd
%tile, 50th%tile for 35 week gestation). She had
hypoglycemia during the first two days of life
however remained in the well baby nursery. She was
discharged home at 7 days of life, which is typical for
neonates in Japan.

Case of YK

At 2 months of age, she developed

neonatal intrahepatic cholestasis,
decreased coagulation factors, hemolytic
anemia, hepatomegaly,
hypoproteinemia, hyperammonemia,
hypoglycemia and fatty liver.

Genetic testing was done at that time

which revealed compound heterozygote
mutations in SLC25A13.

Case of YK

Until the age of 1, she was treated with a diet

consisting of medium chain triglycerides.

At that point, she continued on a diet which was high

in protein and fat and low in carbohydrates, which she
had an aversion for.

At the age of 1.5 years her cholestasis and

dysfunctional liver enzymes had improved; however,
she continued to have several bouts of hypoglycemia
whenever she had diarrhea and/or vomiting. This
improved after the age of 4 years.

Case of YK

She continuously experienced fatigue

and abdominal pain which are typical
with individuals of her condition.

For this reason, she was started on

sodium pyruvate at the age of 7 years
and now eats more carbohydrates which
has decreased her frequency of
abdominal pain to once per month.

Whats the diagnosis?

Citrin Deficiency

Remember the urea cycle??

Lets start from the

beginning

Excess protein that we consume needs

to be broken down by enzymes into
smaller products, like ammonia and
organic acids.

Body must process these large amounts

of ammonia and organic acids into
harmless forms that can be disposed of.

Lets start from the

beginning

Urea

Waste produced by the body after

metabolizing protein

Produced when the liver breaks down

protein or amino acids, and ammonia

Kidneys then transfer the urea from the

blood into the urine

The Urea Cycle

The gene involved

SLC25A13 is located on the long (q) arm

of chromosome 7 at position 21.3.
Provides instructions for making the
protein citrin.
It was discovered in 1999 by a Japanese
group led by Keiko Kobayashi.

The gene involved

Gene structure

SLC25A13 contains 18 exons and

encompasses about 200kb of DNA

Encoded protein is a mitochondrial

aspartate/glutamate carrier

Multiple transcript variants encoding

different isoforms have been found for
this gene.

The gene involved

Two mutations (c.1177+1G>A and

c.851-854del) account for the majority
(~70%) of pathologic alleles in Japanese
persons with citrin deficiency.

Only one mutation, p.Arg360X, has been

found in both Japanese and Northern
European populations

Manifestations of citrin deficiency

1)

2)

3)

Neonatal intrahepatic cholestasis

(NICCD)
Failure to thrive and dyslipidemia in
older children (FTTDCD)
Recurrent hyperammonemia with
neuropsychiatric symptoms in adults
(CTLN2)

Neonatal intrahepatic cholestasis

caused by citrin defiency (NICCD)

Children under the age of 1 year with NICCD have a

transient intrahepatic cholestasis.
Other findings include:

Diffuse fatty liver with hepatomegaly and parenchymal

cellular infiltration a/w hepatic fibrosis
Low birth weight
Growth retardation
Hypoproteinemia
Decreased coagulation factors
Hemolytic anemia
Variable (usually mild) liver dysfunction
Hypoglycemia

Neonatal intrahepatic cholestasis

caused by citrin defiency (NICCD)

Symptoms generally resolve by the time they

are 1 year old with treatment, which includes
fat-soluble vitamin supplementation and use
of lactose-free formulas or formulas
containing medium-chain triglycerides

Starting around the age of 1-2 years, children

begin showing a strong preference for protein
and lipid-rich foods and an aversion to sugar
and carbohydrate-rich foods.

Failure to Thrive and Dyslipidemia

caused by Citrin Deficiency (FTTDCD)

FTTDCD was recently proposed as a novel postNICCD phenotype (before the onset of CTLN2) by
Song et al in 2011.

Traditionally, it was assumed that there was an

apparently healthy period after NICCD but
before the onset of CTLN2.

Dyslipidemia

Abnormal levels of triglyceride and cholesterol

(including total, HDL, and LDL)

Failure to Thrive and Dyslipidemia

caused by Citrin Deficiency (FTTDCD)

In a citrin-deficient cohort of 51 children diagnosed in a

Chinese pediatric center, they analyzed SLC25A13 mutations,
identified dysmorphic erythrocytes, did hepatobiliary
scintigraphic imaging and investigated the post-NICCD
clinical presentations.

Twelve SLC25A13 mutations were detected, along with two

novel mutations.

Among the 51 cases:

7 had echinocytosis which was a/w more severe biochemical

abnormalities.
9 demonstrated a failure to thrive and dyslipidemia, creating a
phenotype that was different from either NICCD or CTLN2

Failure to Thrive and Dyslipidemia

caused by Citrin Deficiency (FTTDCD)

Citrullinemia Type II (CTLN2)

Neuropsychiatric symptoms due to hyperammonemia

that closely resemble those of other hepatic
encephalopathy or urea cycle disorders:

Nocturnal delirium
Aberrant behaviors (aggression, irritability, and hyperactivity)
Delusions
Disorientation
Restlessness
Drowsiness
Loss of memory
Flapping tremor
Convulsive seizures
Coma

Citrullinemia Type II (CTLN2)

Complications that occur in >10%:

Pancreatitis
Hyperlipidemia
Fatty liver
Hepatoma

Biochemical findings for each type

Testing Strategy

Order of testing
1)

2)

3)

4)

Perform quantitative plasma amino acid analysis

(children age 1-4 months).
Measure blood ammonia, plasma amino acids, PSTI,
liver enzymes (when CTLN2 is suspected).
Perform dietary assessment, including food
preferences
Perform molecular genetic testing:

Sequence analysis of SLC25A13, followed by deletion/duplication

analysis if neither or only one disease-causing mutation is identified.

Mode of inheritance, Genotype-Phenotype

Correlations and Penetrance

Autosomal recessive
No significant correlation exists between the
SLC25A13 mutation types and a decreased
level of hepatic enzyme ASS activity/protein
or age of onset in individuals with CTLN2
For NICCD, the male-to-female ratio is
roughly equal.
For CTLN2, the male-to-female ratio is 2.4 to
1.

Prevalence

Until recently, citrin deficiency was thought to be

restricted to Japan; however, it is not recognized
to be pan ethnic.

In Japan, the frequency of homozygotes or

compound heterozygotes for SLC25A13
mutations is 1:17,000 based on a carrier or
heterozygote rate of 1:65.

The observed prevalence of NICCD is 1:100,000

compared to that of CTLN2 which is 1:230,000.

Treatment of Manifestations

NICCD
supplementation of fat-soluble vitamins
and use of lactose-free formula (in those
with galactosemia) or formulas
containing medium-chain triglycerides

Treatment of Manifestations
FTTDCD
Very few treatment measures have been
described
Fed according to food preferences (high
protein and lipid diet).
Administration of sodium pyruvate may
be effective in correcting growth
retardation.

Treatment of Manifestations
CTLN2
Most successful therapy has been liver
transplantation.
Administration of arginine has been
reported to be effective in decreasing
the blood ammonia concentration.

So whats Citrullinemia Type 1?

Also has both an acute neonatal form

and a milder late-onset form

However, the neonatal form is much

more severe!

Hyperammonemia lethargic, poor

feeding, vomiting ICP and death

So whats Citrullinemia Type 1?

Deficiency of the enzyme

arginosuccinate synthase (ASS)
Plasma ammonia concentration can
approach 3000 micromol/L
Plasma quantitative amino acid analysis
shows absence of arginosuccinic acid
and concentration of citrulline >1000
micromol/L

So whats Citrullinemia Type 1?

ASS1 is the only gene in which mutation is

known to cause CTLN1

Treatment involves the Ucylyd protocol

Sodium benzoate and phenylacetate

Metabolically

active compounds that serve as

alternatives to urea for the excretion of waste nitrogen

Failure to control hyperammonia with the

protocol after two doses requires
hemodialysis

Neonatal screening

Citrin deficiency is detectable by tandem

mass spectrometry (MS/MS)

California and other states screen for

citrin deficiency

Texas only screens for Type 1

Citrullinemia

Who does gene testing?

3 labs can perform sequence analysis of

the coding region however none are
located in the US

Several labs (including Baylor) offer

supplemental newborn screening and
amino acid analysis

New research!

New research has shown that the SLC

gene has a very rich transcript diversity
and that cDNA cloning may be a useful
tool in the diagnosis of citrin deficiency.

References

Michiharu Komatsu, et al. Citrin deficiency as a cause of chronic liver

disorder mimicking non-alcoholic fatty liver disease, Journal of Hepatology,
Volume 49, Issue 5, November 2008, Pages 810-820.
(http://www.sciencedirect.com/science/article/pii/S0168827808003553)
Kobayashi K, Saheki T, Song YZ. Citrin Deficiency. 2005 Sep 16 [Updated
2012 Jan 5]. In: Pagon RA, Bird TD, Dolan CR, et al., editors.
GeneReviews [Internet]. Seattle (WA): University of Washington, Seattle;
1993-. Available from: http://www.ncbi.nlm.nih.gov/books/NBK1181/
Song YZ, et al. Genotypic and phenotypic features of citrin deficiency:
Five-year experience in a Chinese pediatric center. Int J Mol Med.
2011;28:3340.
Zhan-Hui Zhang, et al. Molecular analysis of SLC25A13 gene in human
peripheral blood lymphocytes: Marked transcript diversity, and the
feasibility of cDNA cloning as a diagnostic tool for citrin deficiency, Gene,
Volume 511, Issue 2, 15 December 2012, Pages 227-234.
(http://www.sciencedirect.com/science/article/pii/S0378111912011444)

Happy Holidays!