Nutritional ketosis improves exercise metabolism in patients with very long-chain acyl-CoA dehydrogenase deficiency

Jeannette C Bleeker, Gepke Visser*, Kieran Clarke, Sacha Ferdinandusse, Ferdinand H de Haan, Riekelt H Houtkooper, Lodewijk IJlst, Irene L Kok, Mirjam Langeveld, W Ludo van der Pol, Monique G M de Sain-van der Velden, Anita Sibeijn-Kuiper, Tim Takken, Ronald J A Wanders, Michel van Weeghel, Frits A Wijburg, Luc H van der Woude, Rob C I Wüst, Pete J Cox, Jeroen A L Jeneson

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

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Abstract

A maladaptive shift from fat to carbohydrate (CHO) oxidation during exercise is thought to underlie myopathy and exercise-induced rhabdomyolysis in patients with fatty acid oxidation (FAO) disorders. We hypothesised that ingestion of a ketone ester (KE) drink prior to exercise could serve as an alternative oxidative substrate supply to boost muscular ATP homeostasis. To establish a rational basis for therapeutic use of KE supplementation in FAO, we tested this hypothesis in patients deficient in Very Long-Chain acyl-CoA Dehydrogenase (VLCAD). Five patients (range 17-45 y; 4 M/1F) patients were included in an investigator-initiated, randomised, blinded, placebo-controlled, 2-way cross-over study. Patients drank either a KE + CHO mix or an isocaloric CHO equivalent and performed 35 minutes upright cycling followed by 10 minutes supine cycling inside a Magnetic Resonance scanner at individual maximal FAO work rate (fatmax; approximately 40% VO2max). The protocol was repeated after a 1-week interval with the alternate drink. Primary outcome measures were quadriceps phosphocreatine (PCr), Pi and pH dynamics during exercise and recovery assayed by in vivo 31P-MR spectroscopy. Secondary outcomes included plasma and muscle metabolites and respiratory gas exchange recordings. Ingestion of KE rapidly induced mild ketosis and increased muscle BHB content. During exercise at FATMAX, VLCADD-specific plasma acylcarnitine levels, quadriceps glycolytic intermediate levels and in vivo Pi/PCr ratio were all lower in KE + CHO than CHO. These results provide a rational basis for future clinical trials of synthetic ketone ester supplementation therapy in patients with FAO disorders. Trial registration: ClinicalTrials.gov. Protocol ID: NCT03531554; METC2014.492; ABR51222.042.14.

Original languageEnglish
Pages (from-to)787-799
Number of pages13
JournalJournal of Inherited Metabolic Disease
Volume43
Issue number4
Early online date18-Jan-2020
DOIs
Publication statusPublished - Jul-2020

Keywords

  • fatty acid oxidation
  • in vivo(31)P MRS
  • ketone ester
  • mitochondrial energy transduction
  • muscle
  • nutritional ketosis
  • very long-chain acyl-CoA dehydrogenase
  • VLCADD
  • ACID OXIDATION DISORDERS
  • BETA-OXIDATION
  • BIOLOGICAL FEATURES
  • ACETOACETATE ESTERS
  • MUSCLE
  • TRIGLYCERIDES
  • DIAGNOSIS
  • DEFECTS
  • BIOSYNTHESIS
  • TRIHEPTANOIN

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