Characterization and treatment monitoring of ureagenesis disorders using stable isotopes

Urea cycle disorders (UCDs) are a group of rare conditions, possibly life-threatening and without definitive cure besides liver transplantation. Traditional biochemical analyses/biomarkers cannot reliably determine changes in the UC-function from baseline to post-intervention. We describe a UHPLC-HRMS method to assess ureagenesis in plasma and dried blood spots for [$^{15}$N]urea and [$^{15}$N]amino acids, using [$^{15}$N]ammonium chloride as tracer. [$^{15}$N]enrichment of urea and amino acids was studied in controls (n = 22) and patients (n = 59), the latter showing characteristic ureagenesis variations according to their underlying metabolic defect. Follow-up of therapies was successful, as we observed restoration of [$^{15}$N]urea production and lowering of [$^{15}$N]glutamine. There were no adverse events, and only minimal amounts of tracer and samples required with a short sample preparation time and analysis. Thus, the method proved to be safe and efficient to monitor UCD patients of variable severity pre- and post-therapy, being suitable as physiological endpoint for development of therapies.