Phenylalanine-free Diet for Patients With Secondary Hyperphenylalaninemia in ICU

Phenylalanine-free Diet Lowers the Blood Phenylalanine Levels in Patients With High Phenylalanine Level in the Intensive Care Unit

Hyperphenylalaninemia is not only present in patients with congenital phenylketonuria. In adults with critical illness, hyperphenylalaninemia is noted in some patients and is associated with high mortality rate. Hyperphenylalaninemia can cause metabolic acidosis, brain dysfunction, and metabolic disturbance. We would like to see whether the phenylalanine-free milk for congenital phenylketonuria is also effective in lowering the blood phenylalanine concentrations in patients with critical illness in ICU and hyperphenylalaninemia.

Background: Patients in the intensive care unit often suffer from problems such as high metabolic rate and high tissue breakdown rate under the severe stress of critical diseases. Phenylalanine is an amino acid in the human body and is rich in muscle tissue. However, current studies have found that if the concentration of phenylalanine in the blood is abnormally increased, it may indicate that the tissue is decomposing in large quantities. This phenomenon may be related to disease severity. Our recent observational study of patients in the intensive care unit found that patients with elevated blood phenylalanine had a four-fold increase in mortality within one year. The most common cause of phenylalanine concentration elevation in the blood is a rare disease that occurs in infants with congenital metabolic abnormalities, called congenital phenylketonuria (PKU). The abnormally elevated phenylalanine concentration can lead to toxicity and cause brain hypoplasia, mental retardation, consciousness disturbance, and even seizure. These PKU patients must be treated with milk diet that contains low amount of phenylalanine in order to lower the phenylalanine concentrations. At present, in medicine, although there have been clear medical care strategy for infants with congenital PKU, there is still no clear medical care strategy for adult patients. Research purpose: To investigate whether patients with high blood phenylalanine concentration in the intensive care unit can reduce the blood phenylalanine concentration by a diet without phenylalanine, so as to develop personalized high-quality and specific treatments. Methods: We aim to have complete study in 30 patients (based on our previous study, to recruit 30 patients with high phenylalanine, we need 100 ICU patients for screening) Intervention protocol Phenylalanine-free milk will be fed for 3 days after enrollment. The milk is purchased from ABBOTT company. The content of the whole nutrition for a daily need is also personalized based on the calculation by our dieticians. After the completion of the study, diet will be back to normal diet for all patients. Study end points: the 3-day study period completed Blood sampling and examination for Phenylalanine measurement (DBS) Fasting phenylalanine level will be measured by LC/MS-MS using the dry blood spot method (blood sample is collected by finger sting) in all included patients in the next morning after informed consent signed. Blood applied on filter cards is dried for at least 3 h at room temperature. DBS cards are stored at room temperature for 0-6 days prior to analyses. Phenylalanine concentrations in DBS are measured with LC-MS/MS, using a calibration curve in 0.1 N HCl. The report will be received one day after dry blood spot collected. Once the result of measurement shows the concentration of phenylalanine >112 uM, this patient is enrolled for formal study. All enrolled patients will take the measurement of phenylalanine levels by dry blood spot every 12 hours for the following 4 days until study protocol finished. Phenylalanine measurement by UPLC: In the meanwhile, fasting blood will be collected by venipuncture in EDTA-containing tubes on the morning of screening, 2 and 4 days after diet intervention. The collected blood will be used to measure phenylalanine level by UPLC (ultra-performance liquid chromatography). Plasma samples (100μL) are precipitated with 10% sulfosalicylic acid. After protein precipitation and centrifugation, derivatization is initiated by AQC in acetonitrile. Amino acids are then analyzed using the ACQUITY UPLC System, consisting of a Binary Solvent Manager, a Sample Manager, and a Tunable UV detector. We use EmpowerTM 2 Software to control the system and collect data. Separations are performed on a 2.1×100mm ACQUITY BEH C18 column at a flow rate of 0.70mL/min. The average intra-assay coefficient of variation is 2.6% for phenylalanine. The total coefficient of variation is 2.7% for phenylalanine. The detection limit is 3.3μM for phenylalanine. The linear range is 25-500 μM. APACHE II scores Disease severity is evaluated by calculating APACHE II score on the first day of ICU admission.

Intervention protocol Phenylalanine-free milk will be fed for 3 days after enrollment. The milk is purchased from ABBOTT company. The content of the whole nutrition for a daily need is also personalized based on the calculation by our dieticians. After the completion of the study, diet will be back to normal diet for all patients.

Inclusion Criteria: at critical status with APACHE II score >15 (with or without using ventilator); with the need of staying in ICU >48 hours; fasting plasma phenylalanine concentration >112 uM; and age >20 years old Exclusion Criteria: comorbid disorders other than the main cause for ICU admission that might also compromise survival within three months, such as cancer at terminal status; expected life span< 3 days; and undergoing hemodialysis.