Tyrosinaemia type I--an update.

Tyrosinaemia type I is a recessively inherited disorder caused by a deficiency of fumarylacetoacetase (FAH), the last enzyme in tyrosine degradation. The presumed toxic agents are fumaryl- and maleylacetoacetate which are converted to succinylacetone (SA), a metabolite found in increased amounts in urine and plasma of the patients. The major clinical features are progressive liver damage and renal tubular defects with hypophosphataemic rickets. Renal tubular dysfunctions with secondary rickets may be lacking altogether, even in chronic patients. Hepatocellular carcinoma is a major cause of death in the chronic form. Diagnosis of the disorder is made by assay of SA in urine and serum and by determination of FAH in lymphocytes or fibroblasts. Prenatal diagnosis is performed by SA assay in amniotic fluid supernatant and FAH analysis in cultured amniotic fluid cells or chorionic villus material. Presence of a 'pseudodeficiency' gene for FAH prevents prenatal diagnosis by enzyme analysis in some families, and this gene also precludes identification of heterozygotes outside tyrosinaemia families. Immunoblot analyses show that acute patients and some chronic patients lack immunoreactive FAH protein. cDNA probes for FAH have been developed and several polymorphisms related to the FAH gene have been reported, which may allow prenatal diagnosis in families with complex genotypes. The gene for FAH has been mapped to chromosome 15 q23-q25. Liver transplantation is the ultimate treatment; most patients continue to excrete SA in urine after liver transplantation and therefore there is a possibility of kidney disease after transplantation.