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Mitochondrial diseases are a group of heterogenous disorders that share common cellular consequences resulting from mitochondrial dysfunction: (i) decreased ATP production; (ii) increased reliance on alternative anaerobic energy sources; and (iii) increased production of reactive oxygen species. Objective: We evaluated the effect of a combination (COMB) therapy comprising creatine monohydrate, coenzyme Q1 and lipoic acid to target the above mentioned consequences using a randomized, double-blind, placebo-controlled, crossover study design in patients with mitochondrial cytopathies. Results: Compared with placebo, the COMB therapy resulted in lower resting plasma lactate concentrations, lower urinary 8-isoprostane excretion and attenuated the decline of peak dorsiflexion strength in all patient groups. Improved body composition was only observed in patients in the MELAS group. Interpretation: These results suggest that combination therapies targeting multiple final common pathways of mitochondrial dysfunction favorably influence surrogate markers of cellular energy dysfunction. Future therapies should be designed to target specific mitochondrial diseases to provide the greatest therapeutic benefits for those patients. In addition, future studies employing larger sample sizes in homogeneous groups of patients will be required to determine whether such combination therapies will influence function and quality of life. / Thesis / Master of Science (MS)

Abstract This study describes clinical and biochemical consequences of the 3243A→G mutation in the tRNALeu(UUR) gene of the mitochondrial DNA. Mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS syndrome) is usually caused by this mutation. Demyelinating polyneuropathy was observed as a novel feature in a patient with the mutation. Based on electrodiagnostic examination the polyneuropathy was defined as being of the demyelinating, mixed (motor more than sensory) type. In a 1 year follow-up an approximately 7% reduction in both the motor and sensory nerve conduction velocities were observed. The effect and mechanism of action of nicotinamide treatment in a MELAS patient with the 3243A→G was studied. The blood NAD concentration increased linearly, being 24-fold elevated at 6 weeks of treatment. Blood lactate and pyruvate concentration decreased by 50% within three days and 24 h urine lactate content within 2 weeks. A clinical improvement together with a decrease in the lesion volume in magnetic resonance imaging within the first month were observed. Alleviation of the lactate accumulation during the nicotinamide treatment suggested that an increase in the cellular NAD+NADH concentration led to enhancement of the oxidation of reducing equivalents, suggesting that complex I of respiratory chain operates at non-saturating substrate concentration. Myoblasts cultured from patients carrying the 3243A→G mutation and from controls were used to measure ATP, ADP, catalase and superoxide dismutase activity, population growth, apoptotic cell death and the morphology of cytoskeletal components. ATP and ADP concentrations were decreased, suggesting a decrease in the adenylate pool. The superoxide dismutase and catalase activities were higher than in control cells, suggesting an increased production of reactive oxygen species due to respiratory chain dysfunction. No increase in apoptotic cell death was observed in proliferating myoblasts, but randomization of vimentin filament direction and length was observed and decreased population growth was associated with the mutation. The results show that the 3243A→G mutation leads to numerous secondary pathophysiological events. Based on the literature and the results of this study, similarities were found between the pathophysiology of 3243A→G mutation and other neurodegenerative diseases and aging.

Le complexe III de la chaine respiratoire mitochondriale (OXPHOS III) chez S. cerevisiae est assemblé à partir de dix sous-unités structurales codées par le génome soit nucléaire, soit mitochondrial et fait intervenir une douzaine de protéines extrinsèques au complexe. Nous avons étudié l’une d’entre elle, Bcs1, une ATPase oligomérique conservée de la famille des protéines AAA (ATPases Associated with diverse cellular Activities), qui contrôle la dernière étape de l’assemblage du complexe III. Chez l’Homme, des mutations dans l’orthologue de BCS1, BCS1L, sont associées à différentes maladies. Nous avons montré que des mutations dans les résidus conservés du domaine AAA de Bcs1 peuvent être compensées par des mutations dans les sous-unités de l’ATP synthase mitochondriale (OXPHOS V). Ces mutations compensatrices diminuent toutes l’activité d’hydrolyse de l’ATP de l’enzyme et nous avons proposé que la biogenèse du complexe III puisse être modulée selon l’état énergétique mitochondrial par Bcs1 via sa dépendance à l’ATP. Nous avons aussi identifié des mutations compensatrices dans d’autres gènes et le cas particulier de la délétion du RRF1, facteur général du recyclage des ribosomes mitochondriaux, a été étudié. Nous avons montré que l’absence de Rrf1 a un effet différent sur la stabilité et la traduction des divers ARNm mitochondriaux. Nos résultats suggèrent une coopération entre les facteurs généraux et les facteurs spécifiques de la traduction mitochondriale dans le contrôle de l’expression des sous-unités des complexes OXPHOS traduites dans la mitochondrie. / OXPHOS complexes are multi-subunit complexes embedded in the inner mitochondrial membrane. We have studied the assembly factor Bcs1 that is a membrane-bound AAA-ATPase, required for the assembly of complex III. Mutations in the human gene BCS1L are responsible for various mild to lethal pathologies. Extragenic compensatory mutations able to restore the assembly of complex III in yeast bcs1 mutants were found in different genes not directly connected to the complex, revealing new networks of protein interactions. Mutations in catalytic subunits of ATP synthase were identified and thoroughly characterized. This work has allowed us to propose a novel regulatory loop via the ATP-dependent activity of Bcs1 protein, connecting the production of mitochondrial complex III and the activity of the ATP synthase. Moreover, these results hold promise for the development of therapies, targeting the mitochondrial adenine nucleotide pool, in treatment of BCS1-based disorders. We also show that the absence of RRF1, a mitochondrial ribosome recycling factor, is able to compensate defects of bcs1 mutants. Deletion of RRF1 has a differential impact on the stability and translation of mitochondrial mRNAs. Our results suggest cooperation between general and specific translation factors in controlling the expression of mtDNA-encoded subunits of the OXPHOS complexes.

Mitochondria are responsible for many fundamental biological pathways and metabolic processes, including aerobic ATP production by the mitochondrial respiratory chain. In humans, mitochondrial dysfunction can lead to severe disorders of energy metabolism, which are collectively referred to as mitochondrial disorders and affect approximately 1:5,000 individuals. These disorders are clinically heterogeneous and can affect multiple organ systems, often within a single individual. Symptoms can include myopathy, exercise intolerance, hearing loss, blindness, stroke, seizures, diabetes, and GI dysmotility. Mutations in over 150 genes in the mitochondrial DNA (mtDNA) and nuclear genome are known to cause mitochondrial diseases and an additional ~1,000 nuclear-encoded mitochondrial proteins have the potential to underlie mitochondrial disorders but have not yet been linked to human disease. As a result, determining a molecular diagnosis for patients with suspected mitochondrial disorders remains a challenge.

Abstract Finding the genetic causes leading to phenotypes of mitochondrial diseases is challenging because of heterogeneity of the disorders and variety of the underlying biochemical defects. In adults, many of the manifestations of mitochondrial diseases cannot be distinguished from the neurodegenerative processes associated with old age. A single mutation or mutations within the same gene can result in a broad range of disorders. Conversely, clinically similar, monogenic disorders may be caused by genes which are governing entirely different cellular pathways. This study investigated the genetic etiology underlying certain symptoms which are characteristic for mitochondrial syndromes, or mimics of the mitochondrial ones. In the first project, we presented the contribution of genetic variation in the Wolfram Syndrome 1 gene to the risk of diabetes mellitus and sensorineural hearing impairment. We also estimated the frequency of a rare pathogenic variation in WFS1. The second project detected a link between the complex phenotype of age-related hearing impairment and the WFS1 gene. Monogenic forms of ARHI are extremely rare and we succeeded in recognizing one Mendelian form of the trait. The third project confirmed the Mitofusin 2 gene causality in the outlier phenotype of Charcot-Marie-Tooth disease. The fourth project described a Finnish family with two affected siblings with adult-onset ataxia, diabetes mellitus, and hypergonadotropic hypogonadism. The found novel mutation in mtDNA, m.8561C>G, was located in the overlapping region of two mitochondrial genes and resulted in an impaired assembly and dysfunctional energy production of mitochondrial ATP synthase. This thesis expands our knowledge about complex neurological phenotypes and identifies not only some causative genes but also outlier phenotypes, which should be noted in clinical practice. / Tiivistelmä Perintötekijät mitokondriaalisten ja niiden kaltaisten tautien taustalla ovat vaikeasti tunnistettavissa. Tautien kirjo on valtava, ja niihin johtavat biokemialliset syyt ovat moninaisia. Aikuisten mitokondriotaudit voivat jäädä diagnosoimatta, koska oireet voivat peittyä vanhenemiseen liittyviin neurodegeneratiivisiin prosesseihin. Sama mutaatio tai eri mutaatiot samassa geenissä voivat johtaa kliinisesti täysin erilaisiin ilmiasuihin. Toisaalta, kliinisesti samankaltaiset taudit voivat olla geneettisesti ja solubiologiallisesti kirjavia. Tässä tutkimuksessa selvitetään geneettistä etiologiaa tiettyjen mitokondriaalisille ja niiden kaltaisille taudeille tyypillisten oireiden taustalla. Ensimmäisessä osajulkaisussa tunnistetaan geneettisiä riskivariantteja Wolfram Syndrome 1 -geenissä diabeteksen ja kuulonaleneman taustalta. Lisäksi tutkimuksessa estimoidaan harvinaisen tautia aiheuttavan variaation määrää kyseisessä geenissä. Toinen projekti esittelee suomalaisen perheen, jossa myöhään alkaneen kuulonaleneman, ikäkuulon, geneettinen syy paljastuu WFS1-geenistä, jota ei aiemmin ole liitetty kyseiseen ilmiasuun. Yhden geenin aiheuttamat ikäkuulotapaukset ovat todella harvinaisia, koska ikäkuulo on monimutkainen kokonaisuus, johon ympäristötekijöillä on suuri vaikutus. Kolmas osajulkaisu kuvaa potilastapauksia, joiden ilmiasu on epätyypillinen Charcot-Marie-Toothin neuropatia. Tautigeeni on tunnettu Mitofusin 2, mutta sen aiheuttaman taudinkuvat ovat yleensä vakavampia ja varhain alkaneita. Viimeinen osajulkaisu kuvaa suomalaisen perheen, jonka kahden oireisen sisaruksen taustalta löytyy mitokondriaalisen DNA:n uusi mutaatio, joka sijaitsee kahden geenin alueella muuttaen niiden molempien lopputuotetta. Mutaation, m.8561C>G, osoitetaan vaikuttavan mitokondriaalisen ATP-syntaasin rakentumiseen ja energiatuotantoon. Tämä väitöskirja laajentaa geneettistä tietoisuutta neurologisten tautien taustalla ja esittelee uusia geneettisiä syitä ja ilmiasuja, jotka tulisi huomioida kliinisessä työssä terveydenhuollossa.

Mitochondrial diseases are caused by gene mutations in either mitochondrial DNA (mtDNA) or nuclear DNA (nDNA) and they are among one of the most common forms of inherited disorders. It is estimated that 1 out of every 5000 individuals will develop a mitochondrial disease in their lifetime. Due to the crucial and widespread functionality of mitochondria in human cells, prolonged diseases of the mitochondria affect cells of the brain, heart, liver, muscles and kidneys and can lead to multi-organ failure in some patients. Inherited or acquired mitochondrial diseases can present at any stage of life, affecting both children and adults. Since its discovery, the mitochondrial genome has been analyzed and sequenced with increasing ease and this process has helped recognize various mitochondrial disorders as the root of genetic diseases. This paper will explore the unique properties of the mitochondrion and its genome, examine the relationship between mtDNA and some common myopathies such as Leigh syndrome (LS) or maternally inherited Leigh syndrome (MILS), mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) in order to explore commonalities and differences in their inheritance patterns and their effect on mitochondrial function. Although studies have shown that these conditions generally affect the process of oxidative phosphorylation in mitochondria, because of the wide variety of presentations of this disease, further research is needed to understand the different etiologies, as well as to explore novel therapies to treat them.

Les maladies mitochondriales représentent un ensemble très divers de pathologies. Au cours de ce travail, j’ai abordé leur complexité dans deux situations différentes : les déficits humains en complexe III de la chaîne respiratoire mitochondriale et l’analyse des relations génotype/phénotype dans une cohorte de patients suspects de mutations sur un même gène nucléaire (POLG). Le complexe III joue un rôle central au sein de la chaîne respiratoire mitochondriale. Contrairement à sa caractérisation biochimique très complète, son rôle physiologique a été relativement mal établi. D'une cohorte de 2000 patients dont les activités de la chaîne respiratoire mitochondriale avaient été mesurées sur tissu hépatique ou musculaire, nous avons sélectionné 15 patients avec un déficit en complexe III pour lesquels nous disposions de fibroblastes exprimant un déficit respiratoire. L’origine génétique était initialement connue pour quatre des déficits (UQCRB, BCS1L x2, MT-CYB) et, au cours de ce projet, nous avons pu en identifier trois autres (CYC1, MT-CYB, LYRM7). Nous avons cherché à évaluer l'existence d'un lien entre le phénotype et les caractéristiques du déficit : gène impliqué, distribution tissulaire et profil des réponses cellulaires au déficit. Notre population de fibroblastes, hétérogène sur le plan génétique, s’est également révélée très variée quant aux conséquences biochimiques et cellulaires du déficit. Il ne semble donc pas exister de « profil type » des déficits en complexe III. Les atteintes liées à une mutation du gène POLG sont souvent considérées comme les maladies mitochondriales les plus fréquentes chez l’adulte. Elles sont associées à des présentations cliniques très diverses. Nous avons étudié la spécificité et la sensibilité des différents signes cliniques et biologiques considérés comme évocateurs et conduisant donc au séquençage de POLG. A cette fin, nous avons analysé rétrospectivement le phénotype clinique et les investigations mitochondriales chez 154 patients dont le séquençage du gène POLG avait été effectué révélant des mutations touchant les deux allèles du gène chez 34 patients, une seule mutation chez 10 patients et une séquence normale chez 110 patients. L’étude clinique a inclus les signes/symptômes cliniques, les données électrophysiologiques et l'imagerie cérébrale. Les investigations mitochondriales englobaient l’histologie musculaire, le dosage du lactate sanguin, la mesure des activités de la chaîne respiratoire et la recherche de délétions multiples de l’ADN mitochondrial musculaire. Cette étude a montré que les mutations du gène POLG étaient responsables de signes cliniques et paracliniques récurrents présentant donc une sensibilité et une spécificité, notamment en association, permettant de proposer un arbre décisionnel pour l’indication du séquençage du gène POLG. Cette étude a également permis d’établir l’histoire naturelle des maladies de l’adulte dues à des mutations délétères de POLG. En conclusion, la classification des maladies mitochondriales par une anomalie biochimique commune, un déficit en complexe III dans le cas présent, conduit à regrouper des atteintes très différentes, aussi bien sur le plan clinique que biochimique et cellulaire. Au contraire, même dans des affections réputées comme extrêmement diverses comme celles dues aux mutations du gène POLG, la classification par le gène atteint permet d’identifier des présentations récurrentes dans la classe d’âge étudiée, patients adultes dans le cas présent… / Mitochondrial diseases represent a very diverse set of pathologies. With this work, I approached their complexity in two different situations: phenotypic analysis of fibroblasts derived from patients with defects of the respiratory complex III and phenotypic analysis of a cohort of patients, the POLG gene of whom had been sequenced. The complex III plays a central role in the mitochondrial respiratory chain. Contrary to its complete biochemical characterization, its physiological role has been relatively poorly established. We selected 15 patients with complex III defect in liver and/or muscle and with fibroblasts expressing a respiratory defect. The genetic origin was initially known for four of these defects (UQCRB, BCS1L x2, MT- CYB) and during this project, we were able to identify three additional cases (CYC1, MT- CYB, LYRM7). We sought to assess the existence of a link between the disease phenotype and the defect characteristics: gene involved, tissue expression and cellular responses. Our population of fibroblasts, genetically heterogeneous, turned also to be diverse with respect to the biochemical and cellular consequences of the defect. A "typical" profile of complex III defect therefore does not seem to exist. Pathologies related to POLG mutations are often considered the most common mitochondrial diseases in adults. Their clinical presentation is very diverse. We have investigated the specificity and sensitivity of different clinical and biological signs considered as suggestive for POLG mutations and therefore leading to POLG sequencing. To that purpose, we retrospectively analyzed the clinical phenotype and mitochondrial investigations in 154 patients for which POLG had been sequenced revealing mutations affecting two alleles of the gene in 34 patients, one allele for 10 patients and a normal sequence for 110 patients. This study has shown that POLG mutations were responsible of recurrent clinical and paraclinical signs, whose sensitivity and specificity when considered in association allowed to propose a diagnostic flowchart for POLG sequencing. This study has also permitted to establish the natural story of diseases associated with deleterious POLG mutations in adults. In conclusion, classification of mitochondrial diseases by a common biochemical abnormality, a complex III defect in the present case, leads to group very different diseases that differ from their clinical, biochemical and cellular patterns. On the contrary, even in diseases considered highly diverse as those due to POLG mutations, classification by the affected gene allows to identify recurrent presentations in a population of adult patients with neurological presentation.

Mitochondria are the key source of vital ATP molecules, which are largely produced within cells by a system of oxidative phosphorylation (OXPHOS). Genetic defects affecting any of the components of the oxidative phosphorylation system or the structure and function of mitochondria lead to mitochondrial disorders, which occur at an incidence rate of 1 in 5000 live births. Cytochrome c oxidase (COX) is the terminal enzyme and electron acceptor of a respiratory chain that catalyses oxygen to produce a water molecule. In addition to complex I deficiency, isolated or combined COX deficiency is the most common respiratory chain defect in paediatric patients, and it can arise from mutations located either in mitochondrial DNA or in nuclear genes encoding the structural subunits or corresponding assembly factors of the enzyme complex. However, the molecular basis of COX deficiency remains elusive in many patients despite advances in the identification of an increasing number of mutations and genes involved in the disease. This thesis focuses on the identification of the genetic causes of mitochondrial diseases in a cohort of 60 unrelated Czech children with clinically and laboratory confirmed COX-deficiency. With the use of a high-resolution melting analysis mutation screen, four heterozygous sequence...

The complexes of the oxidative phosphorylation (OXPHOS) system in the inner mitochondrial membrane are organised into structural and functional super-assemblies, so-called supercomplexes. This type of organisation enables substrate channelling and hence improves the overall OXPHOS efficiency. ATP synthase associates into dimers and higher oligomers. Within the supercomplex of ATP synthasome, it interacts with ADP/ATP translocase (ANT), which exchanges synthesised ATP for cytosolic ADP, and inorganic phosphate carrier (PiC), which imports phosphate into the mitochondrial matrix. The existence of this supercomplex is generally accepted. Experimental evidence is however still lacking. In this thesis, structural interactions between ATP synthase, ANT and PiC were studied in detail. In addition, the interdependence of their expression was examined either under physiological conditions in rat tissues or using model cell lines with ATP synthase deficiencies of different origin. Specifically, they included mutations in the nuclear genes ATP5E and TMEM70 that code for subunit ε and the ancillary factor of ATP synthase biogenesis TMEM70, respectively, and a microdeletion at the interface of genes MT-ATP6 and MT-COX3 that impairs the mitochondrial translation of both subunit a of ATP synthase and subunit Cox3...