(See also Overview of Undernutrition Overview of Undernutrition Undernutrition is a form of malnutrition. (Malnutrition also includes overnutrition.) Undernutrition can result from inadequate ingestion of nutrients, malabsorption, impaired metabolism, loss... read more .)
The amino acid carnitine is required for the transport of long-chain fatty acyl coenzyme A (CoA) esters into myocyte mitochondria, where they are oxidized for energy. Carnitine is obtained from foods, particularly animal-based foods, and via endogenous synthesis.
Causes of carnitine deficiency include the following:
Inadequate intake (eg, due to fad diets, lack of access, or long-term total parenteral nutrition Total Parenteral Nutrition (TPN) Parenteral nutrition is by definition given IV. Partial parenteral nutrition supplies only part of daily nutritional requirements, supplementing oral intake. Many hospitalized patients are given... read more )
Inability to metabolize carnitine due to enzyme deficiencies (eg, carnitine palmitoyltransferase deficiency, methylmalonicaciduria, propionicacidemia, isovalericacidemia)
Decreased endogenous synthesis of carnitine due to a severe liver disorder
Excess loss of carnitine due to diarrhea, diuresis, or hemodialysis
A hereditary disorder in which carnitine leaks from renal tubules
Increased requirements for carnitine when ketosis is present or demand for fat oxidation is high (eg, during a critical illness such as sepsis or major burns; after major surgery of the gastrointestinal tract)
Decreased muscle carnitine levels due to mitochondrial impairment (eg, due to use of zidovudine)
Use of valproate
The deficiency may be generalized (systemic) or may affect mainly muscle (myopathic).
Symptoms of Carnitine Deficiency
Symptoms of carnitine deficiency and the age at which symptoms appear depend on the cause.
Carnitine deficiency may cause muscle necrosis, myoglobinuria, lipid-storage myopathy, hypoglycemia, fatty liver, and hyperammonemia with muscle aches, fatigue, confusion, and cardiomyopathy.
Diagnosis of Carnitine Deficiency
In neonates: Mass spectrometry
In adults: Acylcarnitine levels
In neonates, carnitine palmitoyltransferase deficiency is diagnosed using mass spectrometry to screen blood. Prenatal diagnosis may be possible using amniotic villous cells.
In adults, the definitive diagnosis is based on acylcarnitine levels in serum, urine, and tissues (muscle and liver for systemic deficiency; muscle only for myopathic deficiency).
Treatment of Carnitine Deficiency
Avoidance of fasting and strenuous exercise
Dietary interventions, based on cause
Carnitine deficiency due to inadequate dietary intake, increased requirements, excess losses, decreased synthesis, or (sometimes) enzyme deficiencies can be treated by giving L-carnitine 25 mg/kg orally every 6 hours.
All patients must avoid fasting and strenuous exercise. Consuming uncooked cornstarch at bedtime prevents early morning hypoglycemia.
Some patients require supplementation with medium-chain triglycerides and essential fatty acids (eg, linoleic acid, linolenic acid). Patients with a fatty acid oxidation disorder Beta-Oxidation Cycle Disorders In these processes, there are numerous inherited defects, which typically manifest during fasting with hypoglycemia and metabolic acidosis; some cause cardiomyopathy and muscle weakness. Beta-oxidation... read more require a high-carbohydrate, low-fat diet.
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