Acute Nutritional Ketosis in VLCAD Deficiency

Not Applicable

Completed

• Conditions: Fatty Acid Oxidation Defects; VLCAD Deficiency
• Interventions: Dietary Supplement: ketone ester drink; Behavioral: exercise; Procedure: muscle biopsy; Diagnostic Test: Magnetic Resonance Imaging

• Registration Number: NCT03531554
• Lead Sponsor: University Medical Center Groningen

Brief Summary

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.

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.

Basic Information
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Recruitment & Eligibility
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Study & Design
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Trial Locations

Study Timeline

• Study Start: 2016-04-01
• Primary Completion: 2017-03-31
• Study Completion: 2017-04-01
• Study First Submitted: 2017-10-17
• Status Verified: 2018-05
• Study First Submitted QC: 2018-05-08
• Last Update Submitted: 2018-05-08
• Study First Posted: 2018-05-21
• Last Update Posted: 2018-05-21

Recruitment & Eligibility

• Status: COMPLETED
• Sex: All
• Target Recruitment: 5

Inclusion Criteria

• Confirmed VLCADD by genetic profiling

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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.

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Study & Design

• Study Type: INTERVENTIONAL
• Study Design: CROSSOVER

Arm && Interventions

Group	Intervention	Description
ketone ester drink	exercise	Oral intake of ketone ester drink muscle biopsy exercise muscle biopsy Magnetic Resonance imaging
ketone ester drink	Magnetic Resonance Imaging	Oral intake of ketone ester drink muscle biopsy exercise muscle biopsy Magnetic Resonance imaging
carbohydrate drink	Magnetic Resonance Imaging	Oral intake of isocaloric carbohydrate drinkmuscle biopsy exercise muscle biopsy Magnetic Resonance imaging
ketone ester drink	ketone ester drink	Oral intake of ketone ester drink muscle biopsy exercise muscle biopsy Magnetic Resonance imaging
carbohydrate drink	muscle biopsy	Oral intake of isocaloric carbohydrate drinkmuscle biopsy exercise muscle biopsy Magnetic Resonance imaging
ketone ester drink	muscle biopsy	Oral intake of ketone ester drink muscle biopsy exercise muscle biopsy Magnetic Resonance imaging
carbohydrate drink	exercise	Oral intake of isocaloric carbohydrate drinkmuscle biopsy exercise muscle biopsy Magnetic Resonance imaging

Primary Outcome Measures

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

Secondary Outcome Measures

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

Trial Locations

Locations (2)

Dept of Neuroscience/ Neuroimaging Center; 🇳🇱 Groningen, Netherlands

Academic Medical Center; 🇳🇱 Amsterdam, Noord-Holland, Netherlands