Dysregulation of the Kennedy Pathway and Tricarboxylic Acid Cycle in ME/CFS (Che et al., 2021) (Pre-print)

[Boba]

dr levine prescribed me this just two days ago. i’ll be starting the fenofibrate tomorrow!

Are u in the U.S.? How did you get hold of Dr.L? Thanks!

 

[Learner1]

Thanks- that's a great paper!

I'm going to quote an excerpt here for the benefit of others:

(spacing added for readability)

That's a nice find.

Garth Nicolson, after doing a lot of research to understand membranes and their dynamics,

https://science.sciencemag.org/content/175/4023/720

has worked to develop treatment, described in this paper:

https://www.sciencedirect.com/science/article/pii/S0005273613004070

"Lipid Replacement Therapy, the use of functional oral supplements containing cell membrane phospholipids and antioxidants, has been used to replace damaged, usually oxidized, membrane glycerophospholipids that accumulate during aging and in various clinical conditions in order to restore cellular function.​

​

This approach differs from other dietary and intravenous phospholipid interventions in the composition of phospholipids and their defense against oxidation during storage, ingestion, digestion and uptake as well as the use of protective molecules that noncovalently complex with phospholipid micelles and prevent their enzymatic and bile disruption. Once the phospholipids have been taken in by transport processes, they are protected by several natural mechanisms involving lipid receptors, transport and carrier molecules and circulating cells and lipoproteins until their delivery to tissues and cells where they can again be transferred to intracellular membranes by specific and nonspecific transport systems. Once delivered to membrane sites, they naturally replace and stimulate removal of damaged membrane lipids. Various chronic clinical conditions are characterized by membrane damage, mainly oxidative but also enzymatic, resulting in loss of cellular function.​

​

This is readily apparent in mitochondrial inner membranes where oxidative damage to phospholipids like cardiolipin and other molecules results in loss of trans-membrane potential, electron transport function and generation of high-energy molecules.​

​

Recent clinical trials have shown the benefits of Lipid Replacement Therapy in restoring mitochondrial function and reducing fatigue in aged subjects and patients with a variety of clinical diagnoses that are characterized by loss of mitochondrial function and include fatigue as a major symptom."​

and this diagram from the paper explains it :

He was driven to learn about this to help his daughter, who had Gulf War Illness and his wife, who had a mycoplasma infection. He found that several infections cause membranes to be damaged (from oxidative and nitrosative stress - a known feature of ME/CFS - see paper I posted above).

He then formulated this product licensed to Allergy Research, Nutricology, and Researched Nutriceuticals, containing the phospholipid constituents of membranes, in the correct ratios, to repair the damaged membranes:

https://www.pureformulas.com/nt-fac...mQeYc1u8vvSs6G8ooOV752hmUtsIdpcgaAkhFEALw_wcB

This strategy, of beating back the virus causing the mito fragmentation, reducing peroxynitrites (oxidative and nitrosative stress) with the Pall protocol (folate, MB12, C and BH4), then replenishing lipids with NT Factor, has he'd to measurable gains of function and in labs for me over the past 3 years.

Which is what Nicolson found and then he also worked with Thomas Seyfried, Dominic D'Agostino and others to publish the mito correction paper, also posted above. He's done other trials finding lipid replenishment reduces fatigue.

 

[Dubitat]

Thanks for another great analysis, @Pyrrhus

Another supplement I'm aware of which acts as a PPAR-alpha agonist is palmitoylethanolamide, which is actually an endogenous compound, and is widely available as a supplement, seeing some usage for treating pain and inflammation.

I tried Palmitoylethanolamide (PEA, not to be confused with phenethylamine) for a few months. It might have produced some minor positive effects, but any changes were small. It also felt like it took a long time to begin working. I will revisit it again.

I've been taking 3-5 grams a day of DHA/EPA, from fish oil for a few years. Shortly after I started taking them, I noticed a reduction in how often I got ME/CFS flares but not PEM.

I still get PEM whenever I do to much physically but I only get flares now every 3-4 months. I think I use to get them about every month or so before I started the high dose fish oil.

The flares I get feel exactly like the flu and usually reduce me to not doing more than a very basic routine but only last about 24 hours. So to only get them every 3-4 months now is a BIG plus!

That's a significant improvement. My experience with fish oil supplements always starts positive but turns negative after several weeks. I've tried different brands and different EPA/DHA ratios, but the result is always more fatigue after an initial improvement.

Whole, prepared fish doesn't have the same negative effects, though. I can eat salmon for 3 meals per day and never get the same negative effects. In some studies, omega-3s from whole fish were more bioavailable than fish oil supplements, so I'm possibly consuming even more omega 3s via fish than I was via fish oil.

That's a nice find.

Garth Nicolson, after doing a lot of research to understand membranes and their dynamics,

https://science.sciencemag.org/content/175/4023/720

has worked to develop treatment, described in this paper:

https://www.sciencedirect.com/science/article/pii/S0005273613004070

NTFactor is an interesting supplement, though I think regular soy lecithin is worth trying before buying the extremely expensive NTFactor branded supplement. NT Factor claims to have a proprietary blend in certain ratios, but I suspect that's mostly marketing. Regular soy lecithin is likely very similar to the proprietary NTFactor soy lecithin extract: https://examine.com/supplements/soy-lecithin/research/#sources-and-composition_composition

A word of caution: Cholinergic supplements are known to cause or worsen depressive symptoms. There are several reports online of NT Factor causing irritability and similar symptoms of cholinergic excess - https://forums.phoenixrising.me/threads/nt-factor-gives-irritability-anxiety-and-rage.80994/

 

[nerd]

Here is the study I meant. It got published now.

Effect of omega-3 fatty acids on cardiovascular outcomes: A systematic review and meta-analysis

doi: 10.1016/j.eclinm.2021.100997

Background
The effects of omega-3 fatty acids (FAs), such as eicosapentaenoic (EPA) and docosahexaenoic (DHA) acids, on cardiovascular outcomes are uncertain. We aimed to determine the effectiveness of omega-3 FAs on fatal and non-fatal cardiovascular outcomes and examine the potential variability in EPA vs. EPA+DHA treatment effects.

Methods
We searched EMBASE, PubMed, ClinicalTrials.gov, and Cochrane library databases through June 7, 2021. We performed a meta-analysis of 38 randomized controlled trials of omega-3 FAs, stratified by EPA monotherapy and EPA+DHA therapy. We estimated random-effects rate ratios (RRs) with (95% confidence intervals) and rated the certainty of evidence using GRADE. The key outcomes of interest were cardiovascular mortality, non-fatal cardiovascular outcomes, bleeding, and atrial fibrillation (AF). The protocol was registered in PROSPERO (CRD42021227580).

Findings
In 149,051 participants, omega-3 FA was associated with reducing cardiovascular mortality (RR, 0.93 [0.88-0.98]; p = 0.01), non-fatal myocardial infarction (MI) (RR, 0.87 [0.81–0.93]; p = 0.0001), coronary heart disease events (CHD) (RR, 0.91 [0.87–0.96]; p = 0.0002), major adverse cardiovascular events (MACE) (RR, 0.95 [0.92–0.98]; p = 0.002), and revascularization (RR, 0.91 [0.87–0.95]; p = 0.0001). The meta-analysis showed higher RR reductions with EPA monotherapy (0.82 [0.68–0.99]) than with EPA + DHA (0.94 [0.89–0.99]) for cardiovascular mortality, non-fatal MI (EPA: 0.72 [0.62–0.84]; EPA+DHA: 0.92 [0.85–1.00]), CHD events (EPA: 0.73 [0.62–0.85]; EPA+DHA: 0.94 [0.89–0.99]), as well for MACE and revascularization. Omega-3 FA increased incident AF (RR, 1.26 [1.08–1.48]). EPA monotherapy vs. control was associated with a higher risk of total bleeding (RR: 1.49 [1.20–1.84]) and AF (RR, 1.35 [1.10–1.66]).

Interpretation
Omega-3 FAs reduced cardiovascular mortality and improved cardiovascular outcomes. The cardiovascular risk reduction was more prominent with EPA monotherapy than with EPA+DHA.

 

[Wishful]

I read a similar meta-analysis several years ago, and it too concluded that omega-3 supplements reduced the risk of heart disease. However, when it came down to actual numbers, high-level supplementation only reduced the risk of a few specific types of heart problems by a few percent. For some reason, they didn't bother to compare that to the risk reduction from moderate daily exercise, which reduces the risk by 75-90%. So, the expensive supplementation (it was way more than one capsule a day) is probably the equivalent of a minute of walking, or some such thing.

Marketers, of course, imply that a capsule a day means that you don't need to exercise or limit your diet...

 

[nerd]

For some reason, they didn't bother to compare that to the risk reduction from moderate daily exercise, which reduces the risk by 75-90%.

It can be a comforting thought for people who can't do real exercise, like ME patients or patients with certain heart conditions. People who exercise might still want to do something in addition. You can't split up the efficacy of a treatment/activity into minutes. There's a lot more happening that depends on long activity, on aerobic activity, and regular activity. I can not imagine that one or even five minutes of activity make any difference.

 

[Wishful]

I probably should have said the equivalent of an extra minute of walking. The point was that the research trials showed only a small percentage improvement (and that could be by manipulating the experiment and data), so the equivalent amount of extra exercise would also be very small. They're probably convinced that a capsule a day means that they don't need to exercise or avoid risky diets or activities.

There are probably some people who are at high risk of heart disease and who could see a higher benefit from fish oils. That doesn't mean that all those people who are presently taking fish oil supplements are getting value for their money.

Poor little fishies, scooped up for a scam.

 

[Pyrrhus]

My experience with fish oil supplements always starts positive but turns negative after several weeks. I've tried different brands and different EPA/DHA ratios, but the result is always more fatigue after an initial improvement.

One possible explanation is that the initially positive result is an anti-inflammatory effect, whereas the longer-term negative result is an immunosuppressive effect. (As strong anti-inflammatory substances tend to become immunosuppressive over time...)

Whole, prepared fish doesn't have the same negative effects, though. I can eat salmon for 3 meals per day and never get the same negative effects.

Same here. I am constantly perplexed by the great disparity in results between food-derived nutrients and supplement-derived nutrients. Problems digesting food (gastritis, exocrine pancreatic insufficiency, etc.) might explain some of these observations.

 

[Pyrrhus]

the following explains how phospholipids (including cardiolipin which we found that ME patients have AntiCardiolipin antibodies) and mitochondrial function are tightly related

Here's a relevant excerpt from the current paper:

The Kennedy pathway is responsible for the biosynthesis of phosphatidylcholines (PC) and phosphatidylethanolamines (PE), the two most abundant phospholipids in mammalian cells. PC, the most abundant phospholipid in the mitochondrial membranes, is sourced from endoplasmic reticulum. PE is synthesized in mitochondria by the decarboxylation of phosphatidylserine by phosphatidylserine decarboxylase 1 (Psd1) at the inner mitochondrial membrane.

PC and PE are essential to the formation of intermediate structures in membrane fusion and fission events, for stabilizing membrane proteins into their optimal conformations, and for actin-filament disassembly in the end stage of cytokinesis. In people with ME/CFS, we found decreased levels of PC and PE and their downstream products: ceramides, sphingomyelins, lysophosphatidycholines, phospholipid ethers, prostaglandin D2 (PGD2) and prostaglandin F2α (PGF2α).

And here's how the authors suggest that the observed reduction in phospholipids might negatively impact the mitochondria:

One critical functional implication of reduced levels of PC and PE is impaired oxidative phosphorylation. PC depletion specifically affects the function of inner membrane protein translocases of mitochondria, including the TIM23 complex. PE synthesis is critical for cytochrome bc1 complex III function in the mitochondrial inner membrane.

Preprotein binding to the TIM/TOM complex, which translocates proteins produced from nuclear DNA through the mitochondrial membrane for use in oxidative phosphorylation, is disturbed in PE-deficient mitochondria. Cytochrome c oxidase activity in the respiratory chain complex is also decreased with PE-deficiency. Reduced import of PE into the mitochondria results in the formation of respiration deficient cells, and in mitochondrial dysfunction.

Finally, reduced levels of lysophosphatidycholines and phospholipid ethers, as well as of PC and PE, can impede mitochondrial respiration. Reduced synthesis of PGF2α and PGD2 in phospholipase A2γ-deficient mice induces mitochondrial dysfunction as well as oxidative stress that can contribute to further mitochondrial damage.

 

[Pyrrhus]

Related discussions:

Naviaux et. al.: Metabolic features of chronic fatigue syndrome
https://forums.phoenixrising.me/thr...c-features-of-chronic-fatigue-syndrome.46486/

Low omega-3 index and polyunsaturated fatty acid status in patients with CFS/ME
https://forums.phoenixrising.me/thr...ty-acid-status-in-patients-with-cfs-me.62356/

Metabolic profiling of me/cfs cohort reveals disturbances in fatty acid & lipid metabolism
https://forums.phoenixrising.me/thr...rbances-in-fatty-acid-lipid-metabolism.48474/

The Deleterious Effects of Oxidative and Nitrosative Stress on Palmitoylation, Membrane Lipid Rafts
https://forums.phoenixrising.me/thr...on-palmitoylation-membrane-lipid-rafts.39656/

 

[Pyrrhus]

This metabolomics paper found decreased levels of certain membrane phospholipids in ME patients compared to controls, notably phosphatidyl-choline, phosphatidyl-ethanolamine, and related plasmalogens. This confirms previous research findings of decreased membrane phospholipids.

Here is a discussion about an in vitro examination of phospholipids in a patient with Postural Orthostatic Tachycardia Syndrome (POTS):
https://forums.phoenixrising.me/threads/choline-deficiency-and-membrane-alteration-in-pots.45006/

 

[Learner1]

NTFactor is an interesting supplement, though I think regular soy lecithin is worth trying before buying the extremely expensive NTFactor branded supplement. NT Factor claims to have a proprietary blend in certain ratios, but I suspect that's mostly marketing. Regular soy lecithin is likely very similar to the proprietary NTFactor soy lecithin extract: https://examine.com/supplements/soy-lecithin/research/#sources-and

I shop around for NT Factor powder that comes in the tub, and can usually find either Nutricologyor Allergy Research for around US$50 vs $92.

It contains phosphatidyl ethanolamine and the other constituents of membranes, in the correct ratios, without having to convert, which can be a problem for some people. A tub lasts me quite a while, even taking a higher dose, And I think it's better than soy lecithin.

A word of caution: Cholinergic supplements are known to cause or worsen depressive symptoms. There are several reports online of NT Factor causing irritability and similar symptoms of cholinergic excess - https://forums.phoenixrising.me/threads/nt-factor-gives-irritability-anxiety-and-rage.80994/

If you have too much choline. Most ME/CFS patients tend to be short of acetylcholine.

Whole, prepared fish doesn't have the same negative effects, though. I can eat salmon for 3 meals per day and never get the same negative effects. In some studies, omega-3s from whole fish were more bioavailable than fish oil supplements, so I'm possibly consuming even more omega 3s via fish than I was via fish oil.

I eat salmon about once a week, maybe twice, and my EPA and DHA are always well into the normal to high normal level. I'm usually short of the alpha linoleic acid which is in flax seeds and need to supplement that

 

[Pyrrhus]

It may be somewhat premature, but for those of you asking about supplements to boost phosphatidyl-choline:

I can share what I have in my notes about choline, which may help:

Lecithin contains phosphatidyl-choline (PC), which is one of the three main forms of supplemental choline.
100mg PC contains 13mg choline.

The other main forms of supplemental choline are citicoline (CDP-choline) and glycero-phospho-choline (GPC).
100mg GPC contains 40mg choline.

Milk contains both PC and GPC. Both PC and GPC are naturally found in the brain.
CDP-choline is temporarily made by the body when synthesizing its own PC.

Since choline synthesis in the body consumes a large percentage of the body's methyl donors, taking supplemental choline should free up a large percentage of the body's methylation capacity.

Choline should not be taken at the same time as carnitine, as they compete with each other for transport across the blood-brain-barrier.

In my own personal case, a single dose of 300mg glycero-phospho-choline (GPC) caused temporary start-up effects of headache, weakness, worsened brain fog, worsened light/sound sensitivity, depression/irritability, preceded by a brief burst of energy and appetite loss.

Over a few weeks, these start-up effects faded and I was able to tolerate two daily doses of 300mg GPC without any problems. For what it's worth...

 

[Learner1]

It may be somewhat premature, but for those of you asking about supplements to boost phosphatidyl-choline:



In my own personal case, a single dose of 300mg glycero-phospho-choline (GPC) caused temporary start-up effects of headache, weakness, worsened brain fog, worsened light/sound sensitivity, depression/irritability, preceded by a brief burst of energy and appetite loss.

Eventually these start-up effects faded and I was able to tolerate two daily doses of 300mg GPC without any problems. For what it's worth...

Phosphatidyl choline is only one of the phospholipids needed in mitochondrial membranes. There are others which are important, too, and there needs to be a balance between them for cell membranes to be healthy.

This discusses the basic concepts of membranes:

https://chem.libretexts.org/Courses...e_Lipids-_Phosphoglycerides_and_Spingholipids

This explains about how phospholipids are synthesized. Note that if you only take choline, you are missing making the stuff in the line from left to right across the bottom, including phosphatidyl serine, phosphatidyl ethanolamine, etc., below the stuff on the purple bubbles...

It's necessary to supplement the others, too. Membranes need a certain ratio of these phospholipids, and NT Factor is formulated to provide all of them in the right ratio.

 

[Dubitat]

It contains phosphatidyl ethanolamine and the other constituents of membranes, in the correct ratios, without having to convert, which can be a problem for some people. A tub lasts me quite a while, even taking a higher dose, And I think it's better than soy lecithin.

NT Factor EnergyLipids (the product linked above) is soy lecithin extract. The ingredient label says so.

They make some unverifiable claims about blending them in the right ratios, but there's no reason to think that the ratios matter that much, or even that they're modifying the ratios significantly. They go out of their way to hide the exact ratios.

Regular NT Factor contains a lot of other supplements, but only in extremely small quantities.

I don't see any reason to think people should spend extra money on NT Factor EnergyLipids soy lecithin extract instead of a regular, significantly cheap soy lecithin extract.

If you have too much choline. Most ME/CFS patients tend to be short of acetylcholine.
I eat salmon about once a week, maybe twice, and my EPA and DHA are always well into the normal to high normal level. I'm usually short of the alpha linoleic acid which is in flax seeds and need to supplement that

Cholinergic activity in the brain and hippocampus specifically isn't controlled by levels of choline in the blood. Taking cholinergic supplements can temporarily spike cholinergic activity, but there are many other factors that influence cholinergic signaling in the brain.

Most blood tests are not useful in determining brain activity of neurotransmitters. Blood levels don't reflect brain levels, and brain levels are only loosely correlated with activity.

High blood levels of choline (by whatever metric) are not necessary for cholinergic depression. Many older antidepressants are anticholinergic and the anticholinergic activity is thought to augment the antidepressant effect. Scopolamine, a powerful anticholinergic, has rapid antidepressant effects in many studies. Even SSRIs like Fluoxetine are known to reduce cholinergic activity in certain brain regions by increasing Acetylcholinesterase.

So ME/CFS patients are not immune from the depressiogenic effects of cholinergic supplements. It's easy to find reports of choline worsening depression or NT Factor causing irritability on this forum.

 

[nerd]

It's necessary to supplement the others, too.

But where to get them?

Meanwhile, Dr. Been discusses cell deformity in the context of LHS and a new method of its detection. Could come down to the same cell membrane pathology.

 

[mariovitali]

Α good question would be : Why is there dysregulation of phospholipid metabolism in the first place ? Is it a consequence of mitochondrial dysfunction?

 

[Learner1]

But where to get them?

NT Factor

https://www.sciencedirect.com/science/article/pii/S0005273613004070

Why is there dysregulation of phospholipid metabolism in the first place ? Is it a consequence of mitochondrial dysfunction?

https://www.clinicaleducation.org/r...-replacement-therapylrt-is-key-to-our-health/

Section 2.3

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3964747/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4566449/

 

[junkcrap50]

Meanwhile, Dr. Been discusses cell deformity in the context of LHS and a new method of its detection. Could come down to the same cell membrane pathology.

Wow. Confirming Leslie Simpson's & Ron Davis's research on RBC deformity in ME/CFS. Maybe should be a seperate thread.

 

[WantedAlive]

Α good question would be : Why is there dysregulation of phospholipid metabolism in the first place ? Is it a consequence of mitochondrial dysfunction?

I like your thinking @mariovitali I’d like to know other diseases where there is dysregulation of the Kennedy pathway that may give us clues to this question. Membranes are such a critical part of cellular function, and mitochondrial function. Considering the complex V inefficiency in ME/CFS, and all the obvious candidates that may be responsible such us UCP’s demonstrated not to be implicated, it set me off to explore the Kennedy Pathway some months back thinking that maybe the mitochondrial membrane is compromised and that’s the cause of the proton leak. To me this study seems really significant and could be responsible for widespread dysfunction if membranes are compromised. Where else is this evident and what part does it play in those diseases?