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Please fill out the following fields Patient information Family name:…………………………………………………………………… Metabolic Unit / DNA Diagnostics Department of Clinical Chemistry First name:……………………………………………….……….……….………. To be filled out by our laboratory: Lab nummer: ................................................................................................. Date of birth: (dd/mm/yyyy)………………………………………………… Datum ontv: ........................................................ Thema: ................. Sex: verrichtingen soort declaratie inschrijven ontvangst e-mail enquête DNA / DNV / PDD / G / RES MLDNA / IND/ FAM/ PRE / N ontv. Male Female invoer afronden / brief supervisie DNA RNA MLPA Please fill out the following fields: Referring physician: ................................................................................................................................ Material Your ref. no: ………………………...... DNA Department: ................................................................................................................................................... Hospital/institute: ......................................................................................................................................... Blood (e.g. 2 ml EDTA) Address:........................................................................................................................................................... Fibroblasts City and Zip-code: ....................................................................................................................................... Lymphoblasts Country: ........................................................................................................................................................... Other: Phone:………………………………………………………Fax: …………………………………………………. E-mail address:............................................................................................................................................. Please indicate if the patient or care Invoice to (if different from above) storage of material for anonymous Name: .............................................................................................................................................................. ........................................................................ keeper does NOT give consent for research. Department: ................................................................................................................................................... Requested test (see page 2 to 4) Hospital/institute: ......................................................................................................................................... prenatal diagnosis, only after consultation Address:........................................................................................................................................................... Gene : …………………………………………… City and Zip-code: ....................................................................................................................................... Known mutation: ………………………………...… Country: ........................................................................................................................................................... Family members previously tested? VAT number (only EU): .......................................................................................................................... No Yes: Our lab nr:……...……………… Name:………………………………………………….... Alternatively an S2 form can be attached, only European countries. Additional information: (e.g. clinical symptoms, biochemistry, pedigree, etc.) Shipment address: VU University Medical Centre Dept. Clinical Chemistry, Metabolic Unit, PK 1X 009 Prof. Dr. Gajja S. Salomons Goederenontvangst - BS6 Van der Boechorststraat 6 1081 BT Amsterdam The Netherlands Directions for collecting and sending samples: 2 ml EDTA blood (one gene) 7 ml EDTA blood (multiple genes) or isolated DNA can be sent at room temperature. Please contact Prof. Gajja Salomons for instructions about molecular prenatal diagnosis. prof. G.S. Salomons, PhD, clinical laboratory geneticist, head Metabolic Unit dr. M.M.C Wamelink, PhD, clinical laboratory geneticist dr. E.A. Struys, PhD, analytical chemist dr. D.E.C. Smith, PhD, analytical chemist secretary Metabolic Unit prof. M.S. van der Knaap, MD PhD, pediatric neurologist dr. N. Wolf, MD PhD, pediatric neurologist dr. M.F. Mulder, MD PhD, pediatrician metabolic diseases dr. J.M. van de Kamp, MD PhD, clinical geneticist dr. M. Williams, MD, PhD, pediatrician metabolic diseases DNA diagnostic_VUMCmetabolic lab EN v7 9, 12/11/2016, Page 1 from 4 [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] tel: +31.20.444 2880 tel: +31.20.444 2881 tel. +31.20.444 2416 tel. +31.20.444 2880 tel: +31.20.444 2880, fax: 444 0305 Metabolic Unit / DNA Diagnostics Department of Clinical Chemistry Please select the requested test(s), for the most up-to-date list please visit www.vumc.com/ML See also at page 4 for the most recently validated genes. Carbohydrate metabolism disorders Fructose-1,6-biphosphatase-1 deficiency (FBP1) Glucan (1,4-alpha-), branching enzyme 1 deficiency / Glycogen storage disease type IV (Andersen) (GBE1) Phosphofructokinase deficiency, muscle type / Glycogen storage disease type VII (Tauri) (PFKM) Ribose 5-phosphate isomerase deficiency (RPIA) Transaldolase deficiency (TALDO1) Transketolase deficiency (TKT) Triosephosphate isomerase deficiency (TPI1) Sedoheptulokinase deficiency (SHPK) Methylmalonic aciduria due to transcobalamin receptor defect (TCbIR / CD320) Cobalamin (B12) metabolism disorders Methylmalonic aciduria, cblA type (MMAA) Methylmalonic aciduria, cblB type (MMAB) Methylmalonic aciduria and homocystinuria, cblC type (MMACHC) Methylmalonic aciduria and homocystinuria, cblD type (MMADHC) Methylmalonic aciduria and homocystinuria, cblF type (LMBRD1) Methylmalonic aciduria and homocystinuria, cblJ type (ABCD4) Methylmalonic acidemia and homocysteinemia, cblX type (X-linked) (HCFC1) 5-Methyltetrahydrofolate-homocysteine methyltransferase deficiency (cblG) (MTR) 5-Methyltetrahydrofolate-homocysteine methyltransferase reductase deficiency (cblE) (MTRR) Methylmalonic aciduria due to transcobalamin receptor defect (TCbIR / CD320) Gastric intrinsic factor deficiency (GIF) Megaloblastic anemia-1, Norwegian type (AMN) Creatine metabolism and transport disorders Arginine:glycine amidinotransferase deficiency (AGAT/ GATM) Creatine transporter defect, X-linked (SLC6A8) Guanidinoacetate methyl transferase deficiency (GAMT) Monocarboxylate transporter 12 deficiency (SLC16A12) Folate metabolism and transport disorders Dihydrofolate reductase deficiency (DHFR) Folate transport deficiency (FOLR1) Methylenetetrahydrofolate reductase deficiency (MTHFR) Methylenetetrahydrofolate dehydrogenase 1 deficiencty (MTHFD1) prof. G.S. Salomons, PhD, clinical laboratory geneticist, head Metabolic Unit dr. M.M.C Wamelink, PhD, clinical laboratory geneticist dr. E.A. Struys, PhD, analytical chemist dr. D.E.C. Smith, PhD, analytical chemist secretary Metabolic Unit prof. M.S. van der Knaap, MD PhD, pediatric neurologist dr. N. Wolf, MD PhD, pediatric neurologist dr. M.F. Mulder, MD PhD, pediatrician metabolic diseases dr. J.M. van de Kamp, MD PhD, clinical geneticist dr. M. Williams, MD PhD, pediatrician metabolic diseases DNA diagnostic_VUMCmetabolic lab EN v7 9, 23/11/2016, Page 2 from 4 GABA metabolism disorders GABA-transaminase deficiency (GABA-T/ ABAT) Succinate semialdehyde dehydrogenase deficiency (SSADH/ ALDH5A1) Hypophosphatemic rickets Dentin matrix acidic phosphoprotein 1 deficiency (DMP1) Ectonucleotide pyrophosphatase / phosphodiesterase 1 deficiency (ENPP1) Sodium phosphate cotransporter, member 3 deficiency (SLC34A3) Lysosomal storage disorders Arylsulfatase A deficiency (ARSA) Mannosidase, beta A, lysosomal deficiency (MANBA) Sulfatase modifying factor 1 deficiency / Multiple sulfatase deficiency (SUMF1) Mucolipidosis IV (ML IV) / mucolipin-1 deficiency (MCOLN1) Lysosomal acid lipase deficiency (LIPA) Galactosylceramidase deficiency / Krabbe disease (GALC) Molybdenum cofactor metabolism disorders Molybdenum cofactor deficiency, type A (MOCS1) Molybdenum cofactor deficiency, type B (MOCS2) Molybdenum cofactor deficiency, type C (GPHN) Organic acidurias Canavan disease (ASPA) D-2-hydroxyglutaric aciduria type I (D2HGDH) D-2-hydroxyglutaric aciduria type II (IDH2) D-2-hydroxyglutaric aciduria with metaphyseal chondromatosis (IDH1) D-2- and L-2-hydroxyglutaric aciduria / mitochondrial citrate transporter (SLC25A1) Glutaric aciduria type 1 (GCDH) L-2-hydroxyglutaric aciduria (L2HGDH) Malonyl-CoA-decarboxylase deficiency (MLYCD) Methylmalonate semialdehyde dehydrogenase deficiency (ALDH6A1) Methylmalonyl CoA mutase deficiency (MUT) Optic atrophy 3 deficiency AD (OPA3) Acyl-CoA synthetase family, member 3 deficiency (ACSF3) Propionyl-CoA carboxylase alpha subunit deficiency (PCCA) Propionyl-CoA carboxylase beta subunit deficiency (PCCB) 2-methylbutyryl glycinuria due to ACADSB deficiency/ 2-methylbutyryl-CoA dehydrogenase deficiency (ACADSB) Purine metabolism disorders Adenosine kinase deficiency (ADK) Adenylosuccinate lyase deficiency (ADSL) [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] tel: +31.20.444 2880 tel: +31.20.444 2881 tel. +31.20.444 2416 tel. +31.20.444 2880 tel: +31.20.444 2880, fax: 444 0305 Pyridoxine (B6) metabolism disorders Pyridoxamine 5'-phosphate oxidase deficiency (PNPO) Pyridoxine dependent epilepsy / Antiquitin deficiency (ALDH7A1) Serine metabolism disorders Phosphoglycerate dehydrogenase deficiency (PHGDH) Phosphoserine aminotransferase 1 deficiency (PSAT1) Phosphoserine phosphatase deficiency (PSPH) Sulphur amino acids metabolism disorders Cystathionine beta-synthase deficiency (CBS) Glycine N-methyltransferase deficiency (GNMT) Methionine adenosyltransferase deficiency (MAT1A) 5-Methyltetrahydrofolate-homocysteine methyltransferase deficiency (cblG) (MTR) 5-Methyltetrahydrofolate-homocysteine methyltransferase reductase deficiency (cblE) (MTRR) S-adenosylhomocysteine hydrolase (SAHH) deficiency (AHCY) Sulfite oxidase deficiency (SUOX) other Transporter disorders Glucose transporter (GLUT1) deficiency (SLC2A1) Hartnup disorder (SLC6A19) Monocarboxylate transporter 12 deficiency (SLC16A12) Sodium-dependent citrate transporter, member 5 deficiency (SLC13A5) Thiamine transporter deficiency (SLC19A3) Lysinuric protein intolerance (LPI) (SLC7A7) Urea cycle disorders and inherited hyperammonaemias Carbamylphosphate synthase 1 deficiency (CPS1) Citrullinemia type 1/ Argininosuccinate synthetase 1 deficiency (ASS1) N-acetylglutamate synthase deficiency (NAGS) Carbonic anhydrase VA deficiency (CA5A) Miscellaneous Alexander disease (GFAP) B-Cell receptor associated protein 31 deficiency(BCAP31) Ceruloplasmin (ferroxidase) deficiency (CP) Myoglobinuria, acute recurrent (Rhabdomyolysis) (LPIN1) Majeed syndrome (LPIN2) LIPIN 3 (LPIN3) Nucleotide-binding protein-like protein deficiency (NUBPL) Quinoid dihydropteridine reductase deficiency (QDPR) Spermine synthase deficiency (Snyder-Robinson) (SMS) Alkaline phosphatase, liver deficiency (ALPL) Congenital disorder of glycosylation, type II d (B4GALT1) Hyperphenylalaninemia, BH4-deficient, A/ 6-pyruvoyltetrahydropterin synthase deficiency (PTS) 17-beta-hydroxysteroid dehydrogenase X deficiency/ 2Methyl-3-Hydroxybutyryl-CoA Dehydrogenase (MHBD) deficiency Transmembrane protein 27 (TMEM27) tRNA synthetases Mitochondrial tRNA synthetases: Alanyl-tRNA synthetase 2 (AARS2) Arginyl-tRNA synthetase 2 (RARS2) Asparaginyl-tRNA synthetase 2 (NARS2) Aspartyl-tRNA synthetase 2 deficiency / Leukoencephalopathy with brain stem and spinal cord involvement and lactate elevation "LBSL" (DARS2) Cysteinyl-tRNA synthetase 2 (CARS2) Glutamyl-t-RNA synthetase 2 deficiency / Leukoencephalopathy with thalamus and brainstem involvement and high lactate "LTBL" (EARS2) Histidyl-tRNA synthetase 2 (HARS2) Isoleucyl-tRNA synthetase 2 (IARS2) LeucyltRNA synthetase 2 (LARS2) Methionyl-tRNA synthetase 2 (MARS2) Phenylalanyl-tRNA synthetase 2 (FARS2) Prolyl-tRNA synthetase 2 (PARS2) Seryl-tRNA synthetase 2 (SARS2) Threonyl-tRNA synthetase 2 (TARS2) Tryptophanyl-tRNA synthetase 2 (WARS2) Tyrosyl-tRNA synthetase 2 (YARS2) Valyl-tRNA synthetase 2 (VARS2) Cytoplasmic tRNA synthetases: Alanyl-tRNA synthetase (AARS) Arginyl-tRNA synthetase (RARS) Asparaginyl-tRNA synthetase (NARS) Aspartyl-tRNA synthetase deficiency / Hypomyelinisation with brainstem and spinal cord involvement and leg spasticity "HBSL" (DARS) Glutamyl-Prolyl-tRNA synthetase (EPRS) Cysteinyl-tRNA synthetase (CARS) Glutaminyl-tRNA synthetase (QARS) Glycyl-tRNA synthetase (GARS) Histidyl-tRNA synthetase (HARS) Isoleucyl-tRNA synthetase (IARS) Leucyl-tRNA synthetase (LARS) Lysyl-tRNA synthetase (KARS) Phenylalanyl-tRNA synthetase, alpha subunit (FARSA) Phenylalanyl-tRNA synthetase, beta subunit (FARSB) Seryl-tRNA synthetase (SARS) Threonyl-tRNA synthetase (TARS) Tryptophanyl-tRNA synthetase (WARS) Tyrosyl-tRNA synthetase (YARS) Valyl-tRNA synthetase (VARS) tRNA synthetases related: Aminoacyl-tRNA synthetase Complex-interacting Multifunctional Protein 1 (AIMP1) Aminoacyl-tRNA synthetase Complex-interacting Multifunctional Protein 2 (AIMP2) D-tyrosyl-tRNA deacylase 1 (DTD1) Eukaryotic translation elongation factor 1 epsilon 1 (EEF1E1) Threonyl-tRNA synthetase-like 2 (TARSL2) X-inactivation studies DNA diagnostic_VUMCmetabolic lab EN v7 9, 23/11/2016, Page 3 from 4 CLIA ID #: 99D1040080 #M045 Non ketotic hyperglycinemia (NKH) Aminomethyltransferase deficiency (AMT) Glycine cleavage system H-protein deficiency (GCSH) Glycine decarboxylase deficiency (GLDC) Glycine transporter 1 deficiency (SLC6A9) Glycine transporter 2 deficiency (SLC6A5) Lipoic Acid synthase deficiency (LIAS) BolA family member 3 deficiency (BOLA3) Glutaredoxin 5 deficiency (GLRX5) Maple syrup urine disease (MSUD) Maple syrup urine disease, type Ia (BCKDHA) Maple syrup urine disease, type Ib (BCKDHB) Maple syrup urine disease, type II (DBT) Dihydrolipoamide dehydrogenase deficiency (MSUD type III) (DLD) DNA diagnostic_VUMCmetabolic lab EN v7 9, 23/11/2016, Page 4 from 4 CLIA ID #: 99D1040080 #M045