1. A LAYMAN’S SUMMARY OF
“Biomarkers of Abnormal Energy Metabolism In Children
with ASD”, Richard Frye, MD PhD, NAJMS July 2012
C AV E AT – I a m a p a r e n t o f a n A S D c h i l d a n d h a v e n o
m e d i c a l t r a i n i n g . I h a v e s u m m a r i z e d D r. F r y e ’s p a p e r
to the best of my ability in the hope that it helps
busy parents access the material. There may be
errors of understanding here. If you have comments
or corrections, e-mail healingsiggy@gmail.Com

2. AS A PARENT, WHY SHOULD YOU CARE ABOUT
THIS STUDY?
 Before we go any further, let me say (in my opinion) why an
ASD parent should care about this study
 To date, most studies on mitochondrial dysfunction in ASD
kids have mainly looked at a small number of biomarkers to
answer the question “do the kids have mitochondrial
disease”?
 This study goes further. It looks at a broad variety of
biomarkers in ASD kids and also looks to suggest what
abnormalities in these biomarkers mean in terms of
physiologic abnormalities in autism
 In some cases, it means the ASD children may have ASD/MD
but that is only one finding. There are other possibilities
discussed, which are worth knowing about.

3. HOW FREQUENT IS MITOCHONDRIAL DISEASE IN
ASD KIDS?
 About 5% of ASD kids have “classic” mitochondrial disease,
according to a Rossignol/Frye study
 These children have clinical symptoms different from the general
ASD population
 We call this the autism/mitochondrial disease (ASD/MD) group
 According to various other studies, about 30-80% of ASD kids
don’t have classic mitochondrial disease but do have impaired
mitochondrial function
 30-80% is quite a range, why such a wide variance? Because the
studies all used different biomarkers to study mitochondrial
function in ASD kids

4. WHAT WAS THE PURPOSE OF THIS STUDY?
 This study seeks to address the limitations of earlier studies
 This study looked at a broad range of biomarkers in a large
sample (133) of ASD kids
 The purpose is to characterize what biomarkers are
elevated
 Also determine how the selected biomarkers correlated to
other markers of mitochondrial function

5. WHAT BIOMARKERS WERE LOOKED AT?
The study specifically looked at these biomarkers in a
morning blood sample with overnight fasting:
 Plasma lactate
 Plasma alanine
 Alanine/Lysine ratio
 Creatine Kinase
 AST level (a measure of liver function)
 Plasma acylcarnitines
If there was an abnormal value, the testing was
repeated.

6. DIAGNOSES AND DEVELOPMENTAL ISSUES IN THE
KIDS IN THE STUDY
Each child in the study had one of the following clinical diagnoses
 Classic autistic disorder (AD) with no motor delay
 PDD-NOS with no motor delay
 AD with motor delay
 PDD-NOS with motor delay
 Isolated speech delay
 ADHD (with hyperactivity)
 ADHD (without hyperactivity)
The study also looked at clinical characteristics like whether the
child had epilepsy or a developmental regression.

7. STUDY FINDINGS

8. STUDY FINDINGS
Over 30% of the children in the sample of 133 were found to
have metabolic abnormalities. Of the children with metabolic
abnormalities, there were four distinct sub-groups -
 Sub-group 1 – Consistently elevated lactate
 Sub-group 2 – Consistently elevated AST
 Sub-group 3 – Consistently elevated alanine/lysine ratio
 Sub-group 4 – Consistent elevations in multiple
acylcarnitines

9. SUB-GROUP 1 – ELEVATED LACTATE
Children with elevated lactate had -
 A higher rate of motor delays
 Higher values for ammonia than controls
 Elevated urine 2-methyl-3-hydroxybutyric acid which may
be due to an ineffecient citric acid cycle
CONCLUSION:
This sub-group of ASD children may indeed have
mitochondrial disease.

10. SUB-GROUP 2 – ABNORMALLY ELEVATED AST VALUES
 AST is a marker for liver function
 Compared to ASD controls, those with highly elevated AST also
had lower 5-oxoproline (also known as pyroglutamate)
 Pyroglutamate is a metabolite of the gamma-glutamyl cycle
which is involved in glutathione utilization and recovery
 Low 5-oxoproline may mean glutathione depletion, which
reduces the liver’s ability to protect itself against oxidative
stress and neutralize toxins
 This could cause liver dysfunction resulting in increased AST
CONCLUSION:
ASD children with elevated AST values may have
oxidative stress rather than mitochondrial disease.

11. SUB-GROUP 3 – ABNORMALLY ELEVATED
ALANINE/LYSINE RATIO
Compared to controls, ASD children with elevated
alanine/lysine ratio had -
 Elevated alanine
 Elevated lactate
 Elevated urine pyruvate
 Higher rate of epilepsy
CONCLUSION:
ASD children with abnormally elevated alanine/lysine ratio
may indeed have mitochondrial disease, which is not due to
any particular genetic abnormality; this may be associated
with a Complex I deficiency.

12. SUB-GROUP 4 – CONSISTENT ELEVATIONS IN
ACYLCARNITINES
Compared to controls, ASD children with consistent
abnormalities in acylcarnitines were found to have -
 Higher C5OH, C12, C14, C14:OH and C16 acylcarnitines –
i.e. carnitines associated with short and long chain fatty
acids but not medium-chain fatty acids are elevated
 Higher urine 3-OH-3-methylglutaric acid, which suggests
citric acid cycl abnormalities
 This pattern of acylcarnitine elevations is not consistent
with any known fatty oxidation disorder

13. SUB-GROUP 4 – CONSISTENT ELEVATIONS IN
ACYLCARNITINES (continued)
 This pattern is consistent with abnormalities seen in a
rodent model when rodents were injected with
propionic acid
 This sub-group of children has a high rate of regression
 Propionic acid can be produced by Clostridia , a bacterial
species seen in children with regressive ASD
CONCLUSION:
ASD children with elevated acylcarntines may not have
mitochondrial disease. Data from an animal model suggests that
these abnormalities may be associated with propionic acid created
by a bacteria species called clostridia.

14. APPENDIX – STUDY DATA

15. WHAT ABNORMALITIES DID THE STUDY FIND?
Biomarker % of kids with abnormalities
Lactate 16.9%
Alanine 1.7%
Alanine/Lysine Ratio 15.9%
Acylcarnitines 23.8%
AST 10.1%
CK 6.8%

16. HOW DID THE ABNORMALITIES CORRELATE TO
DIAGNOSIS ?
Abnormal AD or PDD- Isolated AD PDD- Other
Biomarker NOS with Speech NOS diagnoses
motor delay delay
Lactate 44% --- 12% 44% ---
AST --- --- 25% 63% 13%
Alanine-to- 25% 13% 25% 38% ---
Lysine ratio
Acylcarnitines --- 17% 33% 15% ---
ASD Controls 33% --- 67% --- ---
(no biomarker
abnormalities)

17. HOW DID THE ABNORMALITIES CORRELATE TO
EPILEPSY & REGRESSION?

Biomarker Regression Epilepsy
Lactate 22% 33%
Alanine/Lysine 25% 75%
Ratio
Acylcarnitines 67% 17%
AST 38% 13%
ASD Controls - 55% 33%
no abnormal
biomarkers