Clinical Information

Disorders of creatine synthesis, deficiency of arginine:glycine amidinotransferases (AGAT), and guanidinoacetate methyltransferase (GAMT), and creatine transporter (SLC6A8) deficiency, are collectively described as creatine deficiency syndromes (CDS). AGAT and GAMT deficiencies are inherited in an autosomal recessive manner, while the creatine transporter defect is X-linked. All 3 disorders result in a depletion of cerebral creatine and typically present with global developmental delays, intellectual disability, and severe speech delay. Commonly, patients with CDS develop seizures. Patients with GAMT and the creatine transporter deficiency exhibit behavioral problems and features of autism. Female carriers for the creatine transporter deficiency can have intellectual disability and behavioral problems, and some develop seizures.

Diagnosis is possible by measuring guanidinoacetate (GAA), creatine (Cr), and creatinine (Crn) in plasma and urine. The profiles are specific for each clinical entity. Patients with GAMT deficiency typically exhibit normal to low Cr, very elevated GAA, and low Crn. Patients with AGAT deficiency typically exhibit normal to low Cr, low GAA, and normal to low Crn. In comparison, elevated Cr, normal GAA, normal to low Crn, and an elevated Cr:Crn ratio characterize patients with creatine transporter defect.

Treatment with oral supplementation of creatine monohydrate is available and effective for the AGAT and GAMT deficiencies. Early treatment has been reported to prevent disease manifestations in affected but presymptomatic newborn siblings of individuals with GAMT or AGAT deficiencies. Creatine supplementation has not been shown to improve outcomes in males with the creatine transporter defect. Female carriers of creatine transporter deficiency who have symptoms, however, have been reported to benefit from creatine supplementation.