Specific GAG ratios in the diagnosis of mucopolysaccharidoses

Abstract

Mucopolysaccharidoses (MPS) screening is tedious and still performed by analysis of total glycosaminoglycans (GAG) using 1,9-dimethylmethylene blue (DMB) photometric assay, although false positive and negative tests have been reported. Analysis of differentiated GAGs have been pursued classically by gel electrophoresis or more recently by quantitative LC-MS assays. Secondary elevations of GAGs have been reported in urinary tract infections (UTI). In this manuscript, we describe the diagnostic accuracy of urinary GAG measurements by LC-MS for MPS typing in 68 untreated MPS and mucolipidosis (ML) patients, 183 controls and 153 UTI samples. We report age-dependent reference values and cut-offs for chondroitin sulfate (CS), dermatan sulfate (DS), heparan sulfate (HS) and keratan sulfate (KS) and specific GAG ratios. The use of HS/DS ratio in combination to GAG concentrations normalized to creatinine improves the diagnostic accuracy in MPS type I, II, VI and VII. In total 15 samples classified to the wrong MPS type could be correctly assigned using HS/DS ratio. Increased KS/HS ratio in addition to increased KS improves discrimination of MPS type IV by excluding false positives. Some samples of UTI patients showed elevation of specific GAGs, mainly CS, KS and KS/HS ratio and could be misclassified as MPS type IV. Finally, DMB photometric assay performed in MPS and ML samples reveal four false negative tests (sensitivity of 94%). In conclusion, specific GAG ratios in complement to quantitative GAG values obtained by LC-MS enhance discrimination of MPS types. Exclusion of patients with UTI improve diagnostic accuracy in MPS IV but not in other types.

Keywords: GAG; LC–MS; MPS; chondroitin sulfate; dermatan sulfate; diagnosis; dimethylmethylene blue dye‐binding (DMB) assay; glycosaminoglycans; heparan sulfate; keratan sulfate; mucopolysaccharidosis; ratios; reference values; urinary tract infection.

FIGURE 1

Derived age‐dependent reference values of dermatan sulfate (DS), chondroitin sulfate (CS), heparan sulfate (HS), and keratan sulfate (HS) as well as two specific ratios HS/DS and KS/HS. Boxplots depict the median and quartiles and whiskers the 2.5–97.5 percentiles. The sample sizes for different age groups are: n = 31 (0–0.5 y); n = 20 (0.5–1 y); n = 26 (1–4 y); n = 42 (4–10 y); n = 34 (10–18 y); n = 30 (>18 y).

FIGURE 2

Ratio to cut‐off values (>97.5 p) of dermatan sulfate (DS), chondroitin sulfate (CS), heparan sulfate (HS), and keratan sulfate (HS), as well as specific ratios HS/DS and KS/HS in urine samples of controls (n = 183), urinary tract infection (UTI, n = 153), and untreated patients (n = 68) with mucopolysaccaridosis (MPS) type I, II, III, IV, VI, VII and mucolipidosis (ML). UTI: urinary tract infection.