NORD gratefully acknowledges Allison Kress, Editorial Intern from the University of Notre Dame, Leah Rhodes, MS, Curtis Coughlin II, MSc, MBe, and Johan L. Van Hove, MD, PhD, Department of Pediatrics, Section of Clinical Genetics and Metabolism, University of Colorado School of Medicine, for the preparation of this report.
The severe classic form of NKH typically presents in the first week of life with low muscle tone, lethargy, seizures, coma, and apnea requiring ventilator support. The ventilator is typically needed for a period of 10-20 days before the apnea resolves. A portion of individuals with severe classical NKH die during the neonatal period, often due to withdrawal of intensive care supports. All children with severe classical NKH who survive the neonatal period have severe developmental delay. Most individuals do not reach milestones past those reached by the typical 6-week-old infant. Seizures gradually worsen and can be difficult to control. Feeding difficulties and orthopedic problems can occur. Airway maintenance becomes poor over time due to low muscle tone, and is often the cause of death.
Individuals with attenuated classic NKH can present in the neonatal period or later in infancy. Presentation in the neonatal period resembles that of severe classic NKH. Those who present in infancy can have low muscle tone, lethargy, and seizures. Individuals with attenuated classic NKH have variable developmental progress. Developmental delays can range from mild to profound. They can often walk and achieve various motor skills. They often have hyperactivity and behavioral problems.
The clinical picture of individuals with variant NKH is rapidly evolving. Presentation varies depending upon what gene is mutated and the specific mutation itself. Particular symptoms can include: problems with spasticity or balance, problems with the nerve of the eye (optic neuropathy), problems with the white matter of the brain, heart weakness, increased resistance to blood flow in the lungs, accumulation of acid in the blood, loss of skills that the child had achieved, or seizures. Most children have only some of these problems.
Classic NKH is caused by genetic variants (mutations) in the genes that encode the components of the glycine cleavage enzyme system. This enzyme system is responsible for breaking down the amino acid glycine in the body. When it is not working properly, glycine accumulates in the body, resulting in the symptoms associated with NKH.
The glycine cleavage enzyme system is composed of 4 proteins, the P-protein encoded by the GLDC gene, the H-protein encoded by the GCSH gene, the T-protein encoded by the AMT gene, and the L-protein. Mutations in GLDC or AMT cause classic NKH. The majority of individuals with classic NKH have mutations within the GLDC gene. No mutations have been identified in the GCSH gene.
Individuals with deficient enzyme activity, but no mutation in GLDC or AMT, have variant NKH. Many genes have been described in variant NKH including LIAS, BOLA3, GLRX5, NFU1, ISCA2, IBA56, LIPT1 and LIPT2.
NKH is inherited in an autosomal recessive inheritance pattern, meaning that an individual must have pathogenic variants in both copies of the causative gene in order to be affected. Individuals with a pathogenic variant in only one copy of the gene are carriers for the disorder, and are not affected themselves, but could potentially have an affected child if their partner is also a carrier. If both parents are carriers for NKH, then there is a 1 in 4 chance, with each pregnancy, of the child being affected with NKH.
The incidence of NKH is predicted to be approximately 1:76,000. NKH can occur in individuals of any ancestry.
Cerebral spinal fluid (CSF) and plasma glycine levels are used in the diagnosis of NKH. Deficient enzyme activity causes elevated glycine levels in plasma and CSF, and an elevated CSF:plasma glycine ratio. High glycine levels in plasma and urine are not exclusive to NKH. Increased CSF glycine is highly indicative of NKH, however contamination of CSF with blood or serum can cause a false elevation of CSF glycine. CSF glycine is the preferred diagnostic test. Molecular analysis is an excellent confirmatory test. With sequencing and deletion/duplication analysis, 98% of alleles are detected. Brain MRI imaging can also be helpful because there is a specific pattern of changes seen in individuals with NKH.
Prenatal diagnosis is available when familial mutations are known.
There is no curative treatment for NKH. However, there are treatments that can improve outcomes.
Sodium benzoate is used to reduce serum glycine levels. Benzoate binds to glycine in the body to form hippurate, which is excreted in the urine. This treatment reduces seizures and improves alertness. Plasma glycine levels must be monitored closely to ensure sodium benzoate is at an effective and non-toxic level.
Dextromethorphan is commonly used to reduce seizures and improve alertness. Dextromethorphan binds to NMDA receptors in the brain. These receptors are over-stimulated in individuals with NKH due to increased glycine levels in the brain. Glutamate is the neurotransmitter that predominately binds to these receptors. Dextromethorphan binds to the NMDA receptors, blocking glutamate from binding to the receptor. Ketamine is another NMDA receptor blocker that is also used. In patients with attenuated NKH, use of dextromethorphan can help with attention and chorea, and if treated early together with benzoate, can improve development and seizures.
Seizure management in individuals with severe classic NKH is difficult and usually requires multiple anticonvulsants. Valproate is not recommended for patients with NKH as it inhibits the residual glycine cleavage enzyme activity. Vigabatrin should rarely be used as many children with NKH have had adverse reactions to it.
Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government web site.
For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:
Tollfree: (800) 411-1222
TTY: (866) 411-1010
Email: [email protected]
For information about clinical trials sponsored by private sources, contact:
For information about clinical trials conducted in Europe, contact:
Bjoraker KJ, Swanson MA, Coughlin CR 2nd, Christodolou J, Tan ES, Fergeson M, Dyack S, Ahmad A, Friederich MW, Spector EB, Creadon-Swindell G, Hodge MA, Gaughan S, Burns C, Van Hove JL.Neurodevelopmental Outcome and Treatment Efficacy of Benzoate and Dextromethorphan in Siblings with Attenuated Nonketotic Hyperglycinemia. Journal of Pediatrics 2016;170:234-239.
Coughlin CR 2nd, Swanson MA, Kronquist K, et al. The genetic basis of classical nonketotic hyperglycinemia due to mutations in GLDC and AMT. Genet in Med. 2016 Jun 30. doi: 10.1038/gim.2016.74. [Epub ahead of print]
Hennermann J, Berger JM, Grieben U, Scharer G, Van Hove JL. (2012). Prediction of long-term outcome in glycine encephalopathy: a clinical survey. Journal of Inherited Metabolic Disease 2016;35;253-261.
Swanson, M. A., Coughlin, C. R., Scharer, G. H., Szerlong, H. J., Bjoraker, K. J., Spector, E. B., Creadon-Swindell, G., Mahieu, V., Matthijs, G., Hennermann, J. B., Applegarth, D. A., Toone, J. R., Tong, S., Williams, K. and Van Hove, J. L. K. Biochemical and molecular predictors for prognosis in nonketotic hyperglycinemia. Ann Neurol. 2015 Oct;78(4):606-18. doi: 10.1002/ana.24485. Epub 2015 Aug 10.
Tsuyusaki Y, Shimbo H, Wada T, et al.Paradoxical increase in seizure frequency with valproate in nonketotic hyperglycinemia. Brain Dev. 2012;34:72-75.
Kure S, Kato K, Dinopoulos A, et al. Comprehensive mutation analysis of GLDC, AMT, and GCSH in nonketotic hyperglycinemia. Human Mutation 2006;27:343-352.
Hoover-Fong J E, Shah S, Van Hove J L K, et al.Natural history of nonketotic hyperglycinemia in 65 patients. Neurology 2004;63:1847-1853.
Korman S H, Gutman A.Pitfalls in the diagnosis of glycine encephalopathy (non-ketotic hyperglycinemia). Dev Med Child Neurol. 2002;44:712-720.
The information in NORD’s Rare Disease Database is for educational purposes only and is not intended to replace the advice of a physician or other qualified medical professional.
The content of the website and databases of the National Organization for Rare Disorders (NORD) is copyrighted and may not be reproduced, copied, downloaded or disseminated, in any way, for any commercial or public purpose, without prior written authorization and approval from NORD. Individuals may print one hard copy of an individual disease for personal use, provided that content is unmodified and includes NORD’s copyright.
National Organization for Rare Disorders (NORD)
55 Kenosia Ave., Danbury CT 06810 • (203)744-0100