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.
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
Allocation
RANDOMIZED
Purpose
OTHER
Masking
DOUBLE
Enrollment
5
395 mg of ketone ester/kg
35 min cycling test on an upright bicycle, followed by 10 minutes of supine cycling inside a MR scanner.
biopsy from the quadriceps muscle prior to and immediately after upright bicycling
Academic Medical Center
Amsterdam, North Holland, Netherlands
Dept of Neuroscience/ Neuroimaging Center
Groningen, Netherlands
Change of ATP concentration in millimolar
steady-state in vivo intramuscular concentration of ATP metabolites during rest and exercise.
Time frame: 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.
Time frame: 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.
Time frame: During session 2 and 3: continuous measurements from t=75 minutes until t=85 minutes
kinetic rate constant of ATP synthesis in Hertz
rate constant of Pi and PCr recovery post-exercise
Time frame: 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
Time frame: session 2 and 3, 10 minutes each time
completion of 35 minute upright bicycling bout at FATMAX
(yes/no; if no, #minutes)
Time frame: Session 2 and 3, 35 minutes
completion of 10 minute supine bicycling bout at FATMAX in scanner
(yes/no; if no, #minutes)
Time frame: Session 2 and 3, 10 minutes
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1H MR images and 31P MR spectra were acquired from the upper leg prior to-, during and after exercise
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.
Time frame: 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.
Time frame: 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.
Time frame: 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
Time frame: 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
Time frame: 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
Time frame: 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
Time frame: 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
Time frame: 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
Time frame: 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
Time frame: 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
Time frame: 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
Time frame: 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
Time frame: 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
Time frame: Session 2 and 3, 265 minutes per session
Subjective exertion
Measured with Borg score (range from 6 (rest) to 20 (extreme exertion)).
Time frame: During Session 2 + 3, assessed during blood sampling, 265 minutes per session
height in meters
height of patient
Time frame: 1 minute during screening visit
weight in kilogram
weight of patient to dose intervention and normalize outcome parameters
Time frame: 1 minute during screening visit
BMI in kg/m^2
weight and height will be combined to report BMI in kg/m\^2
Time frame: 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
Time frame: 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
Time frame: 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
Time frame: 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
Time frame: 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.
Time frame: 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.
Time frame: 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.
Time frame: 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.
Time frame: 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.
Time frame: 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.
Time frame: 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.
Time frame: 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.
Time frame: 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.
Time frame: Session 2+3: before and after exercise, 20 minutes per session