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David Taylor
February 2012
Argininaemia
Pathway: Arginase catalyses the fifth step in the urea cycle, in which arginine is
hydrolysed into ornithine and urea (Figure 1). The urea cycle performs a number of
roles: it is the sole source of endogenous arginine, ornithine, and citrulline
production; it is the dominant mechanism for the removal of waste nitrogen form
protein turnover; it is the principal mechanism for metabolism of other nitrogenous
metabolic compounds like adenosine monophosphate; it incorporates enzymes
which overlap with the nitric oxide production pathway (ASS and ASL).
Figure 1: The urea cycle. The enzyme block (arginase) in argininaemia is indicated by the red line.
Genetics:
Argininaemia is inherited in an autosomal recessive manner. The arginase enzyme is
encoded by the ARG1 gene.
Inherited Metabolic Disease Laboratory
David Taylor
February 2012
Clinical Presentation:
In contrast to the other eight urea cycle disorders, arginase deficiency rarely results
in elevated plasma ammonia concentration in the newborn period, even in
individuals whom lack enzyme expression entirely. Episodic hyperammonaemia of
varying concentration can occur, but is rarely severe enough to be life threatening.
Hyperammonaemia is often only detected if measured during an acute illness. It is
thought that 75% of individuals with arginase deficiency survive their disease, living
long, albeit handicapped lives.
In most cases birth and early childhood pass entirely normally. However, from the
ages of 1-3 growth is seen to slow and spasticity (most commonly spastic diplegia)
begins to be observed. Soon after, normal neurological development slows or stops
altogether and the child does not achieve developmental milestones. If the disorder
remains untreated, children progress to severe spasticity, loss of the ability to walk,
loss of bowel and bladder control and severe intellectual disability.
Older individuals have been known to present with arginase deficiency with
postoperative encephalopathy.
Age of onset:
Age of onset of symptoms is typically at 1-3 months following an unremarkable birth
and early infancy.
Biochemistry:
Hyperammonaemia with respiratory alkalosis are common to all urea cycle defects
during periods of metabolic decompensation.
Plasma amino acids: An elevation of plasma arginine concentration 3-4x the upper
limit of normal is highly suggestive of a diagnosis. Note: Up to 2x elevations in
arginine can be seen in infants whom are otherwise normal. In all other urea cycle
defects, arginine concentrations are low.
Urinary orotic acid concentration. Urinary orotic acid concentration is often elevated;
however its measurement is not a primary screen for the disorder.
Inherited Metabolic Disease Laboratory
David Taylor
February 2012
Confirmatory tests:
Enzyme studies using erythrocytes can be used to confirm the diagnosis.
Prenatal Diagnosis:
Genetic prenatal diagnosis is potentially possible where the disease causing mutation
is known, although it does not appear to be currently offered within the UK as a test.
Treatment:
The management of individuals with arginase deficiency closely mirrors those
described for other urea cycle disorders with one caveat: individuals with arginase
deficiency are less prone to episodes of hyperammonaemia. Moreover, when
hyperammonemia is present it is more likely to respond to conservative management
such as intravenous fluid administration. Arginine supplementation is
contraindicated. In infants feeding of 1-1.5 g protein/kg body weight with 50% as
essential amino acids. Older children require lower protein intake.
The seizures which are associated with the disorder are readily treated by
phenobarbital or carbamazepine. Sodium valproate should be avoided, as this is
known to exacerbate hyperammonaemia.
Most individuals with arginase deficiency have persistent hepatic synthetic function
abnormalities, particularly, elevated prothrombin time. In some circumstances
hepatic fibrosis and cirrhosis have developed and have either been fatal or required a
liver transplant.
Pathophysiology:
It is not fully understood what the consequences of persistently raised
concentrations of arginine are.
High concentrations of ammonia (when present) are speculated to have the follwing
consequences. The target of ammonia toxicity in the brain appears to be the
astrocyte, with development of Alzheimer type II astrocytosis being a probable
histopathologic consequence of ammonia toxicity.