Acute Nutritional Ketosis in VLCAD Deficiency

Acute Nutritional Ketosis in VLCAD Deficiency: Testing the Metabolic Base for Therapeutic Use

To test if a ketone-ester based drink can boost muscle mitochondrial function in vivo in patients with VLCADD in order to establish a rational basis for therapeutic use in this disorder.

Study Overview

• Status: Completed
• Conditions: VLCAD Deficiency; Fatty Acid Oxidation Defects
• Intervention / Treatment: Dietary supplement: ketone ester drink; Behavioral: exercise; Procedure: muscle biopsy; Diagnostic test: Magnetic Resonance Imaging

Detailed Description

Exertional rhabdomyolysis is a common symptom in very long-chain acylCoA dehydrogenase deficient (VLCADD) patients. Failing muscle ATP homeostasis, due to impaired fatty acid oxidation, is the most likely cause. Therefore, supplementation with an alternative energy substrate to boost ATP homeostasis, such as an exogenous ketone ester (KE) drink, could be a therapeutic option. Previous results suggest that KE is preferentially oxidized in the tricyclic acid (TCA) cycle and improves physical endurance in athletes. Our primary objective is to test if KE boosts muscular ATP homeostasis in VLCADD patients to establish a rational basis for therapeutic use.

VLCADD patients will be included in a randomized, blinded, placebo controlled, 2-way cross-over trial. Prior to each test, patients receive a KE drink or an isocaloric carbohydrate equivalent, and completed a 35 min cycling test on an upright bicycle, followed by 10 minutes of supine cycling inside a MR scanner. The protocol will be repeated after at least one week with the opposite drink.

• Study Type: Interventional
• Enrollment (Actual): 5
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Netherlands
  • Groningen, Netherlands, 9700RB
    • Dept of Neuroscience/ Neuroimaging Center
  • Noord-Holland
    • Amsterdam, Noord-Holland, Netherlands, 1105 AZ
      • Academic Medical Center

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 16 years to 65 years (Child, Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

- Confirmed VLCADD by genetic profiling

Exclusion Criteria:

• contraindications for MRI studies (assessed by standardised questionnaire as previously used in METC 08-267/K; see UMCG section F METC documents)
• inability to perform bicycle exercise.
• recent episode of rhabdomyolysis, or treatment for acute renal failure in the past 2 months.
• intercurrent illness which may influence exercise tolerance (anaemia, musculoskeletal injury, or other undiagnosed illness under investigation).
• known coronary artery disease, positive history for angina, or changes on ECG suggestive of previous ischaemia without a negative stress test.
• insulin-dependent diabetes mellitus.
• loss of, or an inability to give informed consent.
• pregnancy or current breastfeeding, or females not taking the oral contraceptive pill (this is due to the variability in hormonal patterns and substrate levels with different parts of the menstrual cycle).
• any other cause which in the opinion of the investigators, may affect the volunteers ability to participate in the study.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Other
• Allocation: Randomized
• Interventional Model: Crossover Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: ketone ester drink; Oral intake of ketone ester drink muscle biopsy exercise muscle biopsy Magnetic Resonance imaging	Dietary supplement: ketone ester drink; 395 mg of ketone ester/kg; Other Names: deltaG (R); Behavioral: exercise; 35 min cycling test on an upright bicycle, followed by 10 minutes of supine cycling inside a MR scanner.; Procedure: muscle biopsy; biopsy from the quadriceps muscle prior to and immediately after upright bicycling; Diagnostic test: Magnetic Resonance Imaging; 1H MR images and 31P MR spectra were acquired from the upper leg prior to-, during and after exercise; Other Names: Magnetic Resonance Spectroscopy
Placebo Comparator: carbohydrate drink; Oral intake of isocaloric carbohydrate drinkmuscle biopsy exercise muscle biopsy Magnetic Resonance imaging	Behavioral: exercise; 35 min cycling test on an upright bicycle, followed by 10 minutes of supine cycling inside a MR scanner.; Procedure: muscle biopsy; biopsy from the quadriceps muscle prior to and immediately after upright bicycling; Diagnostic test: Magnetic Resonance Imaging; 1H MR images and 31P MR spectra were acquired from the upper leg prior to-, during and after exercise; Other Names: Magnetic Resonance Spectroscopy

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change of ATP concentration in millimolar	steady-state in vivo intramuscular concentration of ATP metabolites during rest and exercise.	During session 2 and 3: continuous measurements from t=75 minutes until t=85 minutes
Change of PCr concentration in millimolar	steady-state in vivo intramuscular concentration of ATP metabolites during rest and exercise.	During session 2 and 3: continuous measurements from t=75 minutes until t=85 minutes
Change of Pi concentration in millimolar	steady-state in vivo intramuscular concentration of ATP metabolites during rest and exercise.	During session 2 and 3: continuous measurements from t=75 minutes until t=85 minutes

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
kinetic rate constant of ATP synthesis in Hertz	rate constant of Pi and PCr recovery post-exercise	session 2 and 3, 10 minutes each time
intramuscular concentration of H+ in millimolar	steady-state in vivo intramuscular concentration of H+ during rest and exercise	session 2 and 3, 10 minutes each time
completion of 35 minute upright bicycling bout at FATMAX	(yes/no; if no, #minutes)	Session 2 and 3, 35 minutes
completion of 10 minute supine bicycling bout at FATMAX in scanner	(yes/no; if no, #minutes)	Session 2 and 3, 10 minutes
HR in beats per minute	heart rate, VO2 and VCO2 dynamics. During session 2+3 breath sampling will be done for 2 minutes per timepoint, simultaneously with blood sampling.	During session 1, 15 minutes During Session 2 + 3: 35 minutes
VO2 in milliliter per minute per kilogram	heart rate, VO2 and VCO2 dynamics. During session 2+3 breath sampling will be done for 2 minutes per timepoint, simultaneously with blood sampling.	During session 1, 15 minutes During Session 2 + 3: 35 minutes
VCO2 in milliliter per minute per kilogram	VCO2 dynamics during session 2+3 breath sampling for 2 minutes per timepoint, simultaneously with blood sampling.	During session 1, 15 minutes During Session 2 + 3: 35 minutes
Changes in blood metabolites: D-betahydroxybutyrate in millimol per liter	Samples are taken at baseline, 30 minutes, 40 minutes, 50 minutes, 60 minutes, 75 minutes, 85 minutes and 265 minutes after ingestion of the testdrink	Session 2 and 3, 265 minutes per session
Changes in blood metabolites: glucose in millimol per liter	Samples are taken at baseline, 30 minutes, 40 minutes, 50 minutes, 60 minutes, 75 minutes, 85 minutes and 265 min after ingestion of the testdrink	Session 2 and 3, 265 minutes per session
Changes in blood metabolites: lactate in millimol per liter	Samples are taken at baseline, 30 minutes, 60 minutes, 85 minutes and 265 min after ingestion of the testdrink	Session 2 and 3, 265 minutes per session
Changes in blood metabolites: insulin in picomol per liter	Samples are taken at baseline, 30 minutes, 60 minutes, 85 minutes and 265 min after ingestion of the testdrink	Session 2 and 3, 265 minutes per session
Changes in blood metabolites: creatine kinase in units per liter	Samples are taken at baseline, 30 minutes, 60 minutes, 85 minutes and 265 min after ingestion of the testdrink	Session 2 and 3, 265 minutes per session
Changes in blood metabolites: triglycerides in millimol per liter	Samples are taken at baseline, 30 minutes, 60 minutes, 85 minutes and 265 min after ingestion of the testdrink	Session 2 and 3, 265 minutes per session
Changes in blood metabolites: LDL cholesterol in millimol per liter	Samples are taken at baseline, 30 minutes, 60 minutes, 85 minutes and 265 min after ingestion of the testdrink	Session 2 and 3, 265 minutes per session
Changes in blood metabolites: free fatty acids in millimol per liter	Samples are taken at baseline, 30 minutes, 40 minutes, 50 minutes, 60 minutes, 75 minutes, 85 minutes and 265 min after ingestion of the test drink	Session 2 and 3, 265 minutes per session
Changes in blood metabolites: total cholesterol in millimol per liter	Samples are taken at baseline, 30 minutes, 60 minutes, 85 minutes and 265 min after ingestion of the testdrink	Session 2 and 3, 265 minutes per session
Changes in blood metabolites: HDL cholesterol in millimol per liter	Samples are taken at baseline, 30 minutes, 60 minutes, 85 minutes and 265 min after ingestion of the testdrink	Session 2 and 3, 265 minutes per session
Changes in blood metabolites: acylcarnitines in micromol per liter	Samples are taken at baseline, 30 minutes, 40 minutes, 50 minutes, 60 minutes, 75 minutes, 85 minutes and 265 min after ingestion of the test drink	Session 2 and 3, 265 minutes per session
Subjective exertion	Measured with Borg score (range from 6 (rest) to 20 (extreme exertion)).	During Session 2 + 3, assessed during blood sampling, 265 minutes per session
height in meters	height of patient	1 minute during screening visit
weight in kilogram	weight of patient to dose intervention and normalize outcome parameters	1 minute during screening visit
BMI in kg/m^2	weight and height will be combined to report BMI in kg/m^2	1 minute during screening visit
optional: TCA intermediates in muscle tissue (units is ratio of metabolite peak/ internal standard) and will be expressed as fold change from baseline	metabolomics (mass spectrometry) of muscle tissue on a voluntary basis	Session 2+3: before and after exercise, 20 minutes per session
optional: glycolysis intermediates in muscle tissue (units is ratio of metabolite peak/ internal standard) and will be expressed as fold change from baseline	metabolomics (mass spectrometry) of muscle tissue on a voluntary basis	Session 2+3: before and after exercise, 20 minutes per session
optional: acylcarnitines in muscle tissue (units is ratio of metabolite peak/ internal standard) and will be expressed as fold change from baseline	metabolomics (mass spectrometry) of muscle tissue on a voluntary basis	Session 2+3: before and after exercise, 20 minutes per session
optional: D-betahydroxybutyrate in muscle tissue (units is ratio of metabolite peak/ internal standard) and will be expressed as fold change from baseline	metabolomics (mass spectrometry) of muscle tissue on a voluntary basis	Session 2+3: before and after exercise, 20 minutes per session
optional: capillary density in muscle tissue based on CD31 staining (capillaries per millimeter^2)	individual phenotypic muscle properties on a voluntary basis. Immunohistochemistry.	Session 2+3: before and after exercise, 20 minutes per session
optional: mitochondrial density based on ATPase, COX-SDH, SDH and NADH staining (intensity per microgram per minute).	individual phenotypic muscle properties on a voluntary basis. Immunohistochemistry.	Session 2+3: before and after exercise, 20 minutes per session
optional: mitochondrial density based on as citrate synthase activity expressed as absorbance/s/mg.	individual phenotypic muscle properties on a voluntary basis.	Session 2+3: before and after exercise, 20 minutes per session
optional: parameters for metabolism and mitochondrial function in muscle (AMPK, PPAR gamma, PGC1a, and GLUT4). All expressed as protein content as % of control.	individual phenotypic muscle properties on a voluntary basis. Westernblots.	Session 2+3: before and after exercise, 20 minutes per session
optional: lipid accumulation based on Oil-Red-O staining (intensity of staining, and percentage positive-stained cells).	individual phenotypic muscle properties on a voluntary basis. Immunohistochemistry.	Session 2+3: before and after exercise, 20 minutes per session
optional: muscle fiber type composition based on myosin heavy chain profiling. Type I, IIa, IIx fibres will be expressed as % of total fibres.	individual phenotypic muscle properties on a voluntary basis.	Session 2+3: before and after exercise, 20 minutes per session
optional: muscle fiber type composition based on ATPase staining (intensity/ug/min). Type I, IIa, IIx fibres will be expressed as % of total fibres.	individual phenotypic muscle properties on a voluntary basis. Immunohistochemistry.	Session 2+3: before and after exercise, 20 minutes per session
optional: glycogen content of muscle based on Periodic acid-Schiff (PAS) staining (intensity per millimeter^2)	individual phenotypic muscle properties on a voluntary basis. Immunohistochemistry.	Session 2+3: before and after exercise, 20 minutes per session
optional: glycogen content of muscle measured as glucose released after enzymatic digestion with amyloglucosidase expressed as micromol per gram wet muscle weight.	individual phenotypic muscle properties on a voluntary basis.	Session 2+3: before and after exercise, 20 minutes per session

Collaborators and Investigators

• Sponsor: University Medical Center Groningen
• Collaborators: UMC Utrecht; University of Oxford; Academisch Medisch Centrum - Universiteit van Amsterdam (AMC-UvA); ESN (Erfelijke Stofwisselingsziekten Nederland)
• Investigators: Principal Investigator: Jeroen AL Jeneson, PhD, Dept of Neuroscience/ Neuroimaging Center Groningen

Publications and helpful links

General Publications

• Cox PJ, Kirk T, Ashmore T, Willerton K, Evans R, Smith A, Murray AJ, Stubbs B, West J, McLure SW, King MT, Dodd MS, Holloway C, Neubauer S, Drawer S, Veech RL, Griffin JL, Clarke K. Nutritional Ketosis Alters Fuel Preference and Thereby Endurance Performance in Athletes. Cell Metab. 2016 Aug 9;24(2):256-68. doi: 10.1016/j.cmet.2016.07.010. Epub 2016 Jul 27.
• Diekman EF, Visser G, Schmitz JP, Nievelstein RA, de Sain-van der Velden M, Wardrop M, Van der Pol WL, Houten SM, van Riel NA, Takken T, Jeneson JA. Altered Energetics of Exercise Explain Risk of Rhabdomyolysis in Very Long-Chain Acyl-CoA Dehydrogenase Deficiency. PLoS One. 2016 Feb 16;11(2):e0147818. doi: 10.1371/journal.pone.0147818. eCollection 2016.
• Bleeker JC, Visser G, Clarke K, Ferdinandusse S, de Haan FH, Houtkooper RH, IJlst L, Kok IL, Langeveld M, van der Pol WL, de Sain-van der Velden MGM, Sibeijn-Kuiper A, Takken T, Wanders RJA, van Weeghel M, Wijburg FA, van der Woude LH, Wust RCI, Cox PJ, Jeneson JAL. Nutritional ketosis improves exercise metabolism in patients with very long-chain acyl-CoA dehydrogenase deficiency. J Inherit Metab Dis. 2020 Jul;43(4):787-799. doi: 10.1002/jimd.12217. Epub 2020 Feb 5.

Study record dates

Study Major Dates

• Study Start (Actual): April 1, 2016
• Primary Completion (Actual): March 31, 2017
• Study Completion (Actual): April 1, 2017

Study Registration Dates

• First Submitted: October 17, 2017
• First Submitted That Met QC Criteria: May 8, 2018
• First Posted (Actual): May 21, 2018

Study Record Updates

• Last Update Posted (Actual): May 21, 2018
• Last Update Submitted That Met QC Criteria: May 8, 2018
• Last Verified: May 1, 2018

More Information

Terms related to this study

• Keywords: ketone ester; Fatty acid Oxidation Disorders; VLCAD deficiency
• Additional Relevant MeSH Terms: Metabolic Diseases; Nervous System Diseases; Genetic Diseases, Inborn; Musculoskeletal Diseases; Neuromuscular Diseases; Metabolism, Inborn Errors; Lipid Metabolism Disorders; Mitochondrial Diseases; Muscular Diseases; Lipid Metabolism, Inborn Errors
• Other Study ID Numbers: METC2014.492;ABR51222.042.14

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: Undecided

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No