Tetrahydrobiopterin responsiveness in phenylketonuria: prediction with the 48-hour loading test and genotype

Karen Anjema*, Margreet van Rijn, Floris C Hofstede, Annet M Bosch, Carla E M Hollak, Estela Rubio-Gozalbo, Maaike C de Vries, Mirian C H Janssen, Carolien C A Boelen, Johannes G M Burgerhof, Nenad Blau, Margaretha Fokkema, Francjan J van Spronsen

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

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Background: How to efficiently diagnose tetrahydrobiopterin (BH4) responsiveness in patients with phenylketonuria remains unclear. This study investigated the positive predictive value (PPV) of the 48-hour BH4 loading test and the additional value of genotype.

Methods: Data of the 48-hour BH4 loading test (20 mg BH4/kg/day) were collected at six Dutch university hospitals. Patients with >= 30% phenylalanine reduction at >= 1 time points during the 48 hours (potential responders) were invited for the BH4 extension phase, designed to establish true-positive BH4 responsiveness. This is defined as long-term >= 30% reduction in mean phenylalanine concentration and/or >= 4 g/day and/or >= 50% increase of natural protein intake. Genotype was collected if available.

Results: 177/183 patients successfully completed the 48-hour BH4 loading test. 80/177 were potential responders and 67/80 completed the BH4 extension phase. In 58/67 true-positive BH4 responsiveness was confirmed (PPV 87%). The genotype was available for 120/177 patients. 41/44 patients with = 1 mutation associated with long-term BH4 responsiveness showed potential BH4 responsiveness in the 48-hour test and 34/41 completed the BH4 extension phase. In 33/34 true-positive BH4 responsiveness was confirmed. 4/40 patients with two known putative null mutations were potential responders; 2/4 performed the BH4 extension phase but showed no true-positive BH4 responsiveness.

Conclusions: The 48-hour BH4 loading test in combination with a classified genotype is a good parameter in predicting true-positive BH4 responsiveness. We propose assessing genotype first, particularly in the neonatal period. Patients with two known putative null mutations can be excluded from BH4 testing.

Original languageEnglish
Article number103
Number of pages9
JournalOrphanet journal of rare diseases
Publication statusPublished - 10-Jul-2013


  • Phenylketonuria
  • PKU
  • Tetrahydrobiopterin
  • Sapropterin dihydrochloride
  • Pharmacological chaperone
  • Genotype
  • Loading test

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