By facilitating timely diagnosis and treatment initiation, population-wide newborn screening programs have led to important reductions in morbidity and mortality for many rare diseases, including medium-chain acyl-CoA dehydrogenase (MCAD) deficiency and very-long-chain acyl-CoA dehydrogenase (VLCAD) deficiency. Newborn screening has also expanded the spectrum of disease severity for MCAD and VLCAD deficiencies to include a higher proportion of milder cases, raising questions about appropriate disease management. To date there has been no systematic attempt to characterize best management practices in terms of the guidance that is available to those who provide care for MCAD and VCLAD deficiencies; nor has there been an attempt to understand the extent to which current practices align with such currently available guidance. The two projects that are part of this thesis sought to address these research gaps with a particular focus on two key disease-specific management practices we identified in advance as priorities: the use of carnitine supplementation and the recommended duration of fasting. The objective of the first project was to systematically review the quality and content of clinical practice guidelines and/or recommendations for the diagnosis and management of both MCAD and VLCAD deficiencies. Two independent reviewers assessed the eligibility of citations retrieved from a comprehensive search of the peer-reviewed and grey literature. We appraised the quality of the reviewed guidance and extracted information on the content of recommendations. From the 25 guidance documents that met our inclusion criteria, only 7 incorporated evidence reviews, indicating that guidance in this field does not generally meet established methodological standards for the rigorous development of clinical practice guidelines. With respect to content, we identified unclear and inconsistent recommendations regarding fasting times and the use of carnitine supplementation. Further empirical evidence in these areas is necessary to inform the development of future rigorous guidelines. The objective of the second project was to identify actual practices in the management of MCAD deficiency. We conducted a scoping review of published literature on treatment practices around the world and a secondary analysis of data documenting treatments received by participants in a Canadian pediatric cohort study. For the scoping review, citations retrieved from our comprehensive search strategy were screened by two independent reviewers. We extracted information on study characteristics and disease management. Our secondary analysis included longitudinal data for Canadian children with MCAD deficiency, born between 2006 and 2015 and enrolled in a cohort study at one of 13 centres. For both project components, we described carnitine supplementation and fasting times, overall and according to potential indicators of disease severity (genotype, biochemical phenotype). We identified 5 relevant publications in the scoping review and analyzed data for 107 children participating in the Canadian cohort. Management practices related to carnitine supplementation and fasting times for MCAD deficiency were highly variable based on both data sources. There was some evidence of an association between genotype and carnitine use, which, based on the scoping review, may be due to a relationship between genotype and carnitine deficiency. While actual practice was in some ways aligned with the guidance we reviewed in the first project, these results underscore the need for further evidence to address areas of uncertainty that have been prioritized by patients and families, clinicians, and health researchers, including questions regarding the potential to tailor treatment to predicted disease severity and an emphasis on controversial therapies such as carnitine supplementation.

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Le déficit héréditaire en Carnitine Palmitoyl Transférase 2 (CPT2), l’un des déficits de l’oxydation mitochondriale des acides gras (OAG) les plus fréquents, est caractérisé dans sa forme adulte par une myopathie métabolique avec des épisodes récurrents de douleurs musculaires, de myoglobinurie et de rhabdomyolyse, habituellement déclenchés par un exercice prolongé ou un jeûne. A l’heure actuelle, il n’y a pas de traitement pharmacologique efficace pour la correction de ce déficit à l’exception de prise en charge nutritionnelle. Mon travail de thèse a porté sur l’étude du potentiel thérapeutique du composé GSK773 un activateur direct de l’AMP-activated Protein Kinase (AMPK), un senseur énergétique de la cellule, dans des myotubes de quatre patients déficitaires en CPT2. En effet, l'AMPK est considérée comme une cible thérapeutique potentielle dans de nombreux troubles métaboliques ou neurodégénératifs courants associés aux dysfonctionnements mitochondriaux. Nous montrons que le composé GSK773 est capable de stimuler les capacités résiduelles de l’OAG et de corriger le flux d’OAG dans des myotubes déficitaires en CPT2 (n=4) après un traitement par 30µM pendant 48h. L’étude par western-blot et par immunofluorescence montre que le GSK773 augmente la quantité de protéine mutante CPT2. L'analyse des intermédiaires C16-acylcarnitines montre que les myotubes déficients en CPT2 présentent, comme prévu, une accumulation de C16-acylcarnitines significativement diminuée après le traitement par le GSK773. De manière intéressante, l'IF et l’xCELLigence, une nouvelle technique basée sur la mesure de l’impédance électrique en temps réel, montrent un processus de différenciation altéré dans les myotubes de patients déficitaires en CPT2 par rapport aux cellules témoins, qui est corrigé par le GSK773. Nous avons également montré que le GSK773 induit une conversion des fibres musculaires vers les fibres de type I lentes/oxydatives, mais aussi une amélioration générale de la qualité du réseau mitochondrial accompagnée d’une biogenèse mitochondriale et une augmentation du niveau de ROS suggérant que le GSK773 agirait sur la plasticité musculaire. D’un point de vue mécanistique, nous avons montré que les effets du GSK773 passent par l’AMPK, PGC-1α, p38 MAPK et les ROS. Ainsi, ces résultats suggèrent que le GSK773 améliore les paramètres métaboliques et structuraux dans les myotubes déficients en CPT2 et que l'AMPK pourrait représenter une cible thérapeutique hautement pertinente pour la correction pharmacologique du déficit en CPT2. / Carnitine Palmitoyl Transferase 2 (CPT2) deficiency is among the most common inherited defects of mitochondrial fatty acid oxidation (FAO). A frequent phenotype is an early adult-onset myopathy characterized by recurrent episodes of muscle pain, myoglobinuria and rhabdomyolysis usually triggered by prolonged exercise or fasting. To date, there is no treatment of this disorder other than dietary management. AMPK is considered as a potential therapeutic target in many common metabolic or neurodegenerative disorders associated to mitochondrial dysfunctions. Thus, we tested the therapeutic potential of the direct AMPK activator GSK773 in myotubes from four CPT2-deficient patients. We show that GSK773 is able to stimulate residual FAO capacities in a dose- and time-dependent manner. Correction of CPT2 defect is achieved after treatment with GSK773 at 30µM for 48h. Western-blots analysis and Immunostaining shows that GSK773 increases the amount of CPT2 mutant protein. Analysis of acylcarnitine intermediates in the culture media shows that CPT2-deficient myotubes exhibit, as expected, an accumulation of C16-acylcarnitines that is significantly decreased after GSK773 treatment. Surprisingly, immunofluorescence and xCELLigence (a real-time monitoring of cell culture technic) show an impaired differentiation process in CPT2-deficient myotubes that is corrected by GSK773. We also show that GSK773 induces a shift in myosin-heavy-chain isoforms toward slow oxidative fiber types, improves the quality of mitochondrial network with an induction of mitochondrial biogenesis and increases ROS levels, suggesting that GSK773 might induce muscle plasticity. Finally, from a mechanistic point of view, siRNAs experiments showed that the effects triggered by GSK773 implicate AMPK, PGC-1α, ROS and p38 MAPK. Altogether these results suggest that GSK773 improves metabolic and structural parameters in CPT2-deficient myotubes and that AMPK might represent a highly relevant therapeutic target for pharmacological correction of inborn CPT2 deficiency.

Bien que le changement dans le choix des substrats énergétiques des acides gras (AGs) vers les glucides soit considéré comme bénéfique pour le cœur insuffisant, il n’est pas clair à savoir pourquoi les patients atteints de désordres de la β-oxydation (β-OX) des AGs à chaîne longue (AGCLs) développent des troubles du rythme et des cardiomyopathies. De plus, le traitement actuel ne permet pas de prévenir l’apparition du phénotype clinique chez tous les patients, spécifiquement en condition de jeûne ou de stress. Ainsi, plusieurs modèles de souris déficientes pour des enzymes impliquées dans l’oxydation des acides gras ont été développés de manière à améliorer les connaissances de la maladie ainsi que les traitements offerts aux patients. À cet égard, cette étude vise à évaluer le phénotype métabolique et fonctionnel des cœurs de souris déficientes pour le récepteur activé de la prolifération des peroxysomes-α (PPARα), un facteur de transcription des gènes impliqués notamment dans la β-OX des AGs, et pour la déshydrogénase des acyl-CoA à très longue chaîne (very-long chain acyl-CoA dehydrogenase, VLCAD), le déficit de l’oxydation des AGCLs le plus commun chez l’humain. L’approche expérimentale utilisée comprend plusieurs techniques dont (i) la perfusion ex vivo de cœur de souris au travail combinée à l’utilisation de substrats marqués au carbone 13 (13C) et à l’analyse par chromatographie gazeuse-spectrométrie de masse (GCMS), (ii) l’analyse de l’expression génique par qPCR et (iii) l’analyse de l’activité électrique du cœur in vivo par télémétrie. De manière inattendue, les résultats de cette étude menée chez la souris ont permis de mettre en évidence que des déficits pour des protéines impliquées dans l’oxydation des AGCLs sont associés à des altérations du métabolisme (i) des glucides, (ii) des AGs polyinsaturés (AGPIs), et (iii) mitochondrial, incluant l’anaplérose, en plus d’être liés à des désordres de la fonction électrique du cœur, à savoir une prolongation du segment QTc. Pris dans leur ensemble, les résultats de cette thèse pourraient servir à l’élaboration de nouvelles interventions métaboliques destinées à améliorer les traitements possibles et donc, la qualité de vie des patients atteints de désordres héréditaires de la β-OX des AGCLs. / While a shift from fatty acids to carbohydrate is considered beneficial for the failing heart, it is unclear why patients with fatty acid oxidation disorders present clinical manifestations such as cardiomyopathy, arrhythmia and conduction defects. Unfortunately, the current nutritional treatment for these patients is limited in its ability to prevent these symptoms, especially under fasting and stress conditions. Many mouse models of fatty acid oxidation deficiency have been developed to improve the knowledge of the disease and the treatment of these patients. In this regard, this study aims to characterize the metabolic and functional phenotype of hearts from mice that are deficient for the peroxisome proliferator-activated receptor α, a transcription factor for gene involved in fatty acid oxidation, and very long chain acyl-CoA dehydrogenase, the most common inherited long chain fatty acid oxidation disorder in human, under various conditions. In this study, numerous approaches have been used, which includes validated experimental paradigms, namely, (i) ex vivo heart perfusion in the working mode with concomitant evaluation of myocardial contractility and metabolic fluxes, employing 13C-labeled substrates combined with mass isotopomer analysis by gas chromatography coupled to mass spectrometry, (ii) gene expression analysis by qPCR and (iii) electrocardiogram monitoring in vivo by telemetry. Unexpectedly, results from the present thesis demonstrate that fatty acid oxidation disorders cause alterations in metabolism of (i) carbohydrates (ii) polyunsaturated fatty acids of the omega-3 type, specifically docosahaexanoic acid, and (iii) mitochondria including anaplerosis, in addition to lead to functional abnormalities, namely a prolongation of the QT interval. Altogether, results from this thesis could contribute to new metabolic therapy development to improve the quality of life of the patients with inherited long chain fatty acid oxidation disorder.

Bien que le changement dans le choix des substrats énergétiques des acides gras (AGs) vers les glucides soit considéré comme bénéfique pour le cœur insuffisant, il n’est pas clair à savoir pourquoi les patients atteints de désordres de la β-oxydation (β-OX) des AGs à chaîne longue (AGCLs) développent des troubles du rythme et des cardiomyopathies. De plus, le traitement actuel ne permet pas de prévenir l’apparition du phénotype clinique chez tous les patients, spécifiquement en condition de jeûne ou de stress. Ainsi, plusieurs modèles de souris déficientes pour des enzymes impliquées dans l’oxydation des acides gras ont été développés de manière à améliorer les connaissances de la maladie ainsi que les traitements offerts aux patients. À cet égard, cette étude vise à évaluer le phénotype métabolique et fonctionnel des cœurs de souris déficientes pour le récepteur activé de la prolifération des peroxysomes-α (PPARα), un facteur de transcription des gènes impliqués notamment dans la β-OX des AGs, et pour la déshydrogénase des acyl-CoA à très longue chaîne (very-long chain acyl-CoA dehydrogenase, VLCAD), le déficit de l’oxydation des AGCLs le plus commun chez l’humain. L’approche expérimentale utilisée comprend plusieurs techniques dont (i) la perfusion ex vivo de cœur de souris au travail combinée à l’utilisation de substrats marqués au carbone 13 (13C) et à l’analyse par chromatographie gazeuse-spectrométrie de masse (GCMS), (ii) l’analyse de l’expression génique par qPCR et (iii) l’analyse de l’activité électrique du cœur in vivo par télémétrie. De manière inattendue, les résultats de cette étude menée chez la souris ont permis de mettre en évidence que des déficits pour des protéines impliquées dans l’oxydation des AGCLs sont associés à des altérations du métabolisme (i) des glucides, (ii) des AGs polyinsaturés (AGPIs), et (iii) mitochondrial, incluant l’anaplérose, en plus d’être liés à des désordres de la fonction électrique du cœur, à savoir une prolongation du segment QTc. Pris dans leur ensemble, les résultats de cette thèse pourraient servir à l’élaboration de nouvelles interventions métaboliques destinées à améliorer les traitements possibles et donc, la qualité de vie des patients atteints de désordres héréditaires de la β-OX des AGCLs. / While a shift from fatty acids to carbohydrate is considered beneficial for the failing heart, it is unclear why patients with fatty acid oxidation disorders present clinical manifestations such as cardiomyopathy, arrhythmia and conduction defects. Unfortunately, the current nutritional treatment for these patients is limited in its ability to prevent these symptoms, especially under fasting and stress conditions. Many mouse models of fatty acid oxidation deficiency have been developed to improve the knowledge of the disease and the treatment of these patients. In this regard, this study aims to characterize the metabolic and functional phenotype of hearts from mice that are deficient for the peroxisome proliferator-activated receptor α, a transcription factor for gene involved in fatty acid oxidation, and very long chain acyl-CoA dehydrogenase, the most common inherited long chain fatty acid oxidation disorder in human, under various conditions. In this study, numerous approaches have been used, which includes validated experimental paradigms, namely, (i) ex vivo heart perfusion in the working mode with concomitant evaluation of myocardial contractility and metabolic fluxes, employing 13C-labeled substrates combined with mass isotopomer analysis by gas chromatography coupled to mass spectrometry, (ii) gene expression analysis by qPCR and (iii) electrocardiogram monitoring in vivo by telemetry. Unexpectedly, results from the present thesis demonstrate that fatty acid oxidation disorders cause alterations in metabolism of (i) carbohydrates (ii) polyunsaturated fatty acids of the omega-3 type, specifically docosahaexanoic acid, and (iii) mitochondria including anaplerosis, in addition to lead to functional abnormalities, namely a prolongation of the QT interval. Altogether, results from this thesis could contribute to new metabolic therapy development to improve the quality of life of the patients with inherited long chain fatty acid oxidation disorder.

Newborn screening programs measure analyte levels in neonatal blood spots to identify individuals at high risk of disease. Carnitine and acylcarnitine levels are primary markers used in the detection of fatty acid oxidation disorders. These analytes may be influenced by certain pre/perinatal or newborn screening related factors. The primary objective of this study was to explore the association between these characteristics and levels of blood carnitines and acylcarnitines in the newborn population. The study was composed of two parts: a systematic review and a clinical database analysis of existing newborn screening data. The systematic review results suggested considerable variability across studies in the presence and directionality of associations between analyte levels and birth weight, gestational age, age at time of blood spot collection, type of sample, and storage time. Sex was not significantly associated with carnitine or acylcarnitine levels in neonatal blood. We identified a need to more fully investigate a potential interaction between gestational age and birth weight in regard to analyte levels. The secondary data analyses indicated a statistically significant relationship between analyte levels and all perinatal / infant and newborn screening related factors of interest, but effect sizes were generally small. The interaction between gestational age and birth weight was significant in all models; when further explored through graphical analysis with conditional means, extremely premature neonates stood out as having distinct analyte patterns in relation to birth weight. Variation in the ratio of total acylcarnitine to free carnitine was better accounted for by the perinatal and newborn factors than was variation in any individual carnitine or acylcarnitine, indicating that proportions of carnitine and acylcarnitines may be more important in understanding an individual’s metabolic functioning than individual analyte levels. A low proportion of variation was explained in all multivariate models, supporting the use of universal algorithms in newborn screening and suggesting the need for further large scale empirical research targeted at previously unaccounted for perinatal factors such as birth stress.

Newborn screening programs measure analyte levels in neonatal blood spots to identify individuals at high risk of disease. Carnitine and acylcarnitine levels are primary markers used in the detection of fatty acid oxidation disorders. These analytes may be influenced by certain pre/perinatal or newborn screening related factors. The primary objective of this study was to explore the association between these characteristics and levels of blood carnitines and acylcarnitines in the newborn population. The study was composed of two parts: a systematic review and a clinical database analysis of existing newborn screening data. The systematic review results suggested considerable variability across studies in the presence and directionality of associations between analyte levels and birth weight, gestational age, age at time of blood spot collection, type of sample, and storage time. Sex was not significantly associated with carnitine or acylcarnitine levels in neonatal blood. We identified a need to more fully investigate a potential interaction between gestational age and birth weight in regard to analyte levels. The secondary data analyses indicated a statistically significant relationship between analyte levels and all perinatal / infant and newborn screening related factors of interest, but effect sizes were generally small. The interaction between gestational age and birth weight was significant in all models; when further explored through graphical analysis with conditional means, extremely premature neonates stood out as having distinct analyte patterns in relation to birth weight. Variation in the ratio of total acylcarnitine to free carnitine was better accounted for by the perinatal and newborn factors than was variation in any individual carnitine or acylcarnitine, indicating that proportions of carnitine and acylcarnitines may be more important in understanding an individual’s metabolic functioning than individual analyte levels. A low proportion of variation was explained in all multivariate models, supporting the use of universal algorithms in newborn screening and suggesting the need for further large scale empirical research targeted at previously unaccounted for perinatal factors such as birth stress.

Newborn screening programs measure analyte levels in neonatal blood spots to identify individuals at high risk of disease. Carnitine and acylcarnitine levels are primary markers used in the detection of fatty acid oxidation disorders. These analytes may be influenced by certain pre/perinatal or newborn screening related factors. The primary objective of this study was to explore the association between these characteristics and levels of blood carnitines and acylcarnitines in the newborn population. The study was composed of two parts: a systematic review and a clinical database analysis of existing newborn screening data. The systematic review results suggested considerable variability across studies in the presence and directionality of associations between analyte levels and birth weight, gestational age, age at time of blood spot collection, type of sample, and storage time. Sex was not significantly associated with carnitine or acylcarnitine levels in neonatal blood. We identified a need to more fully investigate a potential interaction between gestational age and birth weight in regard to analyte levels. The secondary data analyses indicated a statistically significant relationship between analyte levels and all perinatal / infant and newborn screening related factors of interest, but effect sizes were generally small. The interaction between gestational age and birth weight was significant in all models; when further explored through graphical analysis with conditional means, extremely premature neonates stood out as having distinct analyte patterns in relation to birth weight. Variation in the ratio of total acylcarnitine to free carnitine was better accounted for by the perinatal and newborn factors than was variation in any individual carnitine or acylcarnitine, indicating that proportions of carnitine and acylcarnitines may be more important in understanding an individual’s metabolic functioning than individual analyte levels. A low proportion of variation was explained in all multivariate models, supporting the use of universal algorithms in newborn screening and suggesting the need for further large scale empirical research targeted at previously unaccounted for perinatal factors such as birth stress.