Evaluating Mitochondrial Dysfunction in Patients With Neurofibromatosis Type 1
Conditions: Neurofibromatosis 1
Sponsor: University of Arkansas

Title:  Evaluating mitochondrial dysfunction in patients with neurofibromatosis type 1 
PI:  Erika Santos Horta, MD 
 
 
Version #:  v3. 
Date:  5/18/2023  
Page 1 
 
 
 
Study Title:Evaluating mitochondrial dysfunction in patients with neurofibromatosis type 1 
 
 
Principal Investigator:  
Erika Santos Horta, MD 
University of Arkansas for Medical Sciences 
4301 W. Markham Street, Slot # 809 
Little Rock, AR 72205 
Telephone:  5016865838 
Email:  esantoshorta@uams.edu 
 
 
Sub-Investigator (s): 
Grover P. Miller 
( or Faculty Advisor for 
University of Arkansas for Medical Sciences 
 Student projects) 
Biomedical Research Center I_B421A 
Little Rock, AR 72205 
Telephone:  (501) 5266486 
Email millergroverp@uams.edu 
 
Nukhet Aykin-Burns 
 
University of Arkansas for Medical Sciences 
Biomedical Research Center II_435-2 
Little Rock, AR 72205 
Telephone:  +1 (501) 6031375 
Email:  aykinburnsnukhet@uams.edu 
 
Study location: 
Winthrop P Rockefeller Cancer Institute 
 
 
 
 

Title:  Evaluating mitochondrial dysfunction in patients with neurofibromatosis type 1 
PI:  Erika Santos Horta, MD 
 
 
Version #:  v3. 
Date:  5/18/2023  
Page 2 
 
Background and Rationale 
Neurofibromatosis 1 (NF1) is the most common type of neurofibromatosis with a broad 
spectrum of clinical manifestations in multiple organs of the body, including benign and 
malignant tumors (1–3). This autosomal dominant disease arises from several thousand  
genetic variants in the chromosome 17, but about 50% of the mutations are de novo (25). 
Moreover, mitochondrial DNA mutations in the loop region of the genome were seen in 37% of 
cutaneous neurofibromas and in 50% of plexiform neurofibromas, as also in non-tumor cells like 
non-affected skin cells (28). Although it is unclear if those mitochondrial mutations have 
functional effects, other evidence implicates that the impairment of neurofibromin causes 
mitochondrial dysfunction (MD).  
The relation between neurofibromin and mitochondria is structural and functional. Neurofibromin 
can be co-localized within and extracted from mitochondria (26). Losing neurofibromin, 
guanosine-5'-triphosphate (GTP) hydrolysis decreases, activating RAS, a protein complex that 
stimulates mitochondrial degradation (27). Neurofibromin might also modulate mitochondrial 
respiration. Animal models showed mitochondrial respiration inhibition characterized by 
increased superoxide anion production and decreased adenosine triphosphate (ATP) 
generation that was reverted with transgene expression of neurofibromin (9). Loss of 
neurofibromin also activates extracellular signal-regulated-1/2 (ERK 1/2), affecting its interaction 
with mitochondrial chaperone tumor necrosis factor receptor associated protein 1 (TRAP1), 
decreasing succinate coenzyme Q reductase(10,27). Although NF1 animal models show 
mitochondrial dysfunction, literature evaluating mitochondrial function in patients with NF1 is 
scarce. Another factor possibly impacting mitochondrial function is the use of MEK inhibitors. 
These drugs are the only FDA-approved treatment for plexiform neurofibroma, a type of tumor 
that grows in the nerves of NF1 patients. MEK inhibitors can cause an increase in the oxygen 
consumption rate, and they can alter the mitochondrial metabolism affecting complex I and the 
electron transport chain (24,29). We hypothesize that NF1 patients exhibit a range of MD 
that contributes to adverse health outcomes. Validation of this hypothesis will establish a 
bioenergetic phenotype among NF1 patients to better stratify them than current clinical 
descriptions. This information will then be used for identifying relationships between patient 
symptoms and mitochondrial function to demonstrate its value in the clinic (Aim 1). Further, 
patient mitochondrial function will serve as an important mechanistic readout on the 
consequences of neurofibromin mutations and impacts of other factors including lifestyle, diet, 
and drugs (like MEK inhibitors) that can improve or harm mitochondrial function (Aim 2). These 
findings would expand beyond the current limitations of results from model neurofibromin 
knockout studies to more relevant complexities observed with patients. Taken together, 
information gained from patient mitochondrial function assessments would create opportunities 
to develop more personalized, targeted therapeutic interventions for improving patient 
outcomes. 
The mitochondrial function in patients with NF1 and how it correlates with clinical symptoms will 
be investigated for the first time in this proposed study. This novel experimental design will 
generate more clinically relevant findings in humans than current in vitro and in vivo animal 
studies. Moreover, the strategy leverages a minimally invasive blood test using peripheral blood 
mononuclear cells (PBMCs) to assess mitochondrial function. Studies with PBMCs detected 
metabolic stress in patients and acted as biomarkers for MD in diseases including diabetes (22), 
neurodegenerative disease (23), cardiovascular disease (21), as well as many cancers (14–16). 
The proposed study will be the first demonstration of PBMCs as biomarkers for MD for NF1 
patients. This new technique will expand the phenotyping toolbox for patients to include 

Title:  Evaluating mitochondrial dysfunction in patients with neurofibromatosis type 1 
PI:  Erika Santos Horta, MD 
 
 
Version #:  v3. 
Date:  5/18/2023  
Page 3 
 
bioenergetic demands due to the disease as well as in response to interventions like the 
growing field of MEK inhibitors for NF1 treatment (1,4,24). This pilot project’s candidate 
biomarker approach on mitochondrial function focuses on clinically relevant questions such as 
fatigue, pain, cardiac, and renal function. However, our results could be correlated with other 
important NF1 phenotypes and even data from future systemic unbiased multi-omics 
approaches to interpret their meaning within patient bioenergetics.   
 
Hypothesis and/or Specific Aims or Objectives 
Neurofibromatosis 1 (NF1) is one of the most common hereditary tumor predisposition 
syndromes afflicting ~1 in 2750 people worldwide (1,2). Hallmark traits include peripheral and 
central nervous system tumors along with skin and eye lesions, cognitive deficiencies, 
musculoskeletal abnormalities, and multiple types of cancer (2,3). The clinical phenotype arises 
from point mutations (90%) and deletions of the NF1 tumor suppressor gene encoding 
neurofibromin (4). A well-characterized neurofibromin function is stimulation of Ras GTPase 
activity leading to Ras inactivation and suppression of its signals through multiple effectors, 
including mTOR, MEK, ERK, and potentially cAMP/PKA indirectly (5–7). Emerging evidence 
suggests that neurofibromin regulates cellular and organismal metabolism. The decreased 
respiratory quotients (ratio of eliminated CO2 to consumed O2) reported for NF1 patients 
implicate neurofibromin defects as a source of altered basal metabolic rates (8). Similarly, 
animal knockout models have reduced respiratory quotients and increased energy expenditures 
(9–11).  Further analysis of isolated cells lacking neurofibromin show lower basal and coupled 
respiration, lowered maximal and spare respiratory capacities, and elevated reactive oxygen 
species, underscoring the importance of neurofibromin on mitochondrial function (10). 
Supplementation with L-carnitine, a mitochondrial nutrient important for fatty acid oxidation and 
gluconeogenesis, improved weakness and fatigue in NF1 patients (12,13). Due to a diverse 
array of genetic lesions, we hypothesize that NF1 patients exhibit a range of mitochondrial 
dysfunction (MD) as contributing factors to adverse health outcomes. We will test the 
hypothesis by isolating peripheral blood mononuclear cells (PBMCs) from NF1 patients 
recruited through the new Adult UAMS Neurofibromatosis Clinic at the Winthrop P. Rockefeller 
Cancer Institute and measure mitochondrial function for correlative studies with clinical 
phenotypes and symptoms. While novel for NF1 patient studies, the use of PBMCs for 
mitochondrial studies has precedence in assessing function with a variety of cancers and other 
diseases (14–23). The effort for this NF1 pilot study involves expertise in pathogenesis and 
treatment of NF1 (Dr. Erika Santos-Horta), mitochondrial biology (Dr. Nukhet Aykin-Burns), and 
metabolism (Dr. Grover P. Miller) to achieve the following aims: 
 
Aim 1: Demonstrate mitochondrial respiration efficiency of PBMCs inversely correlates 
with clinical symptoms of NF1 patients.  
We will use an Agilent Seahorse XF Pro Analyzer to measure the cellular and mitochondrial 
bioenergetics of PBMC isolated from NF1 patients. We predict patients with milder symptoms of 
fatigue, pain, liver and cardiac function, creatine kinase (CK), and body mass index (BMI) will 
demonstrate better mitochondrial function in their circulating cells.   
 
 
 

Title:  Evaluating mitochondrial dysfunction in patients with neurofibromatosis type 1 
PI:  Erika Santos Horta, MD 
 
 
Version #:  v3. 
Date:  5/18/2023  
Page 4 
 
Aim 2: Assess whether therapeutic interventions impact mitochondrial function and 
metabolic plasticity of circulating cells of NF1 patients.  
We hypothesize that MD among NF1 patients sensitizes them to therapeutic interventions 
targeting mitochondria. We will assess the impact of vitamin D treatment to potentially improve 
mitochondrial function and explore if MEK inhibitors like Koselugo (KOS, Selumetinib, FDA-
approved treatment of plexiform neurofibromas in NF1) harm mitochondrial function in patients 
with NF1, due to their impact in the RAS pathway (24). We predict that the impact of treatments 
on mitochondrial function will lead to insights on mechanisms of action for NF1 patients and 
possibly serve as diagnostic and/or prognostic biomarkers for patient outcomes.   
Preliminary findings will demonstrate a powerful, novel approach for assessing and 
understanding the differences in bioenergetic status among NF1 patients and open new 
research venues. The next steps will study the degree of MD and its correlation with 1) different 
NF1 mutations (deletions, truncations), 2) other NF1 complications like cognition outcome and 
quality of life, and 3) prevalence and prognosis of cancers. 
Hence, this proposal will generate future projects that will aid the team in achieving the long-
term goal of determining mechanisms driving NF1 clinical phenotypes and symptoms to stratify 
and treat patients. To that end, this pilot study will foster a collaborative team across disciplines 
and departments at UAMS to leverage the first and only neurofibromatosis clinic in Arkansas at 
UAMS for improving adult NF1 patient care, and also expand the spectrum of research done by 
the Drs. Miller and Aykin-Burns, who have not researched populations with genetic diseases so 
far, and Dr. Santos Horta, who has not researched mitochondrial function. 
 
Study Design and Procedures (sometimes called “Methods”) 
Although all NF1 patients have genetic changes in the same gene, the clinical presentations of 
the disease are widely diverse. Thus, it is important to determine non-invasive biomarkers that 
would help stratifying NF1 patients, who present with highly variable and unpredictable clinical 
manifestations. Some of the comorbidities seen in NF1 are also shared with patients with 
mitochondrial diseases (e.g., short stature, fatigue, pain). Thus, our main goal will be to 
demonstrate a co-association of clinical symptoms and MD that exists in these patients.   
 
Aim 1: Demonstrate that mitochondrial respiration efficiency of PBMCs inversely 
correlates with clinical symptoms of NF1 patients.  
Parameters associated with MD of PBMCs will be assessed as potentially shared cellular 
pathology in NF1 patients. We hypothesize that MD based on parameters (e.g., coupling 
efficiency and respiratory capacity) positively correlates with more adverse outcomes as 
reflected in the symptoms of fatigue, pain, liver, kidney, and cardiac function. Patients over 18 
years old, previously diagnosed with NF1, will be eligible for this project. A subject will be 
registered in the study only after obtaining a signed copy of the Informed Consent Form, 
completing all pretreatment evaluations, meeting all eligibility criteria, and presenting no 
exclusion criteria. The neurofibromatosis clinic at UAMS currently cares for  100 patients a year, 
and it is in a phase of expansion. It is expected that the clinic will see  100 to 140  patients in the 
next year. We will also recruit 10 to 15  healthy individuals as the control group. Mitochondrial 
function and cellular bioenergetics will be measured in PBMCs and platelets isolated from blood 
collected at consent and every 3-4 months for one year. Freshly isolated cells will be plated in 
coated XF96-Pro well plates using assay media, and the plate will be centrifuged. After the 

Title:  Evaluating mitochondrial dysfunction in patients with neurofibromatosis type 1 
PI:  Erika Santos Horta, MD 
 
 
Version #:  v3. 
Date:  5/18/2023  
Page 5 
 
attachment is confirmed, the cells will be then incubated in a non-CO2 incubator for 20 min at 
37°C. The cellular bioenergetics of PBMCs or platelets will be determined by using a standard 
mitochondrial stress test as we previously published via consecutively injecting oligomycin, an 
uncoupler (FCCP), and the mitochondrial electron transport chain blockers antimycin A and 
rotenone into the wells as we previously published (30–37). Clinical repercussions of MD in NF1 
will be measured through serial scores of fatigue and pain on the same days that PBMC and 
platelets are collected. Fatigue will be assessed through the Functional Assessment of Chronic 
Illness Therapy-Fatigue (FACIT-F). FACIT-F is the only fatigue scale that has been validated in 
dermatological and painful disease, as it is commonly used in neurological disorders (38). Pain 
will be assessed by the NRS-11 scale, as recommended by the patient-reported outcome group 
of the Response Evaluation in Neurofibromatosis and Schwannomatosis (REIS) (39). Other 
biochemical and metabolic functions to be followed will be CK, cardiac function through 
echocardiogram, body mass index, liver, and kidney function.   
 
Aim 2: Assess whether therapeutic interventions impact mitochondrial function and 
metabolic plasticity of circulating cells of NF1 patients. We hypothesize that NF1 patients’ 
inherent mitochondrial dysfunction makes them more responsive to therapeutic interventions 
resulting in further mitochondrial injury (e.g., by MEK inhibitors, including KOS) or improved 
function (e.g., by vitamin D). Most patients are vitamin D deficient so the standard of care 
involves supplementation that could improve mitochondrial function given its essential role in 
many related processes. Also, we will carry out an exploratory study on the potential adverse 
effects of KOS on adult NF1 patients who are beginning therapy during the study window. While 
promising in treatment, the use of this drug has a high incidence of significant adverse side 
effects like cardiotoxicity (30%). The cause for toxicity is unknown yet may involve further 
compromised mitochondrial function as reported for other similar tyrosine kinase inhibitors (40). 
The combination of these studies will provide a critical preliminary assessment of the sensitivity 
of the mitochondrial measures to patient interventions as well as the possible capacity to 
correlate with favorable or harmful outcomes.  
Subjects who present to the clinic and match the inclusion/exclusion criteria for either the NF1 
or control group will be provided a copy of the consent for review. A thorough discussion of the 
consent will be provided by study staff. If the subject agrees to participate, the following will be 
completed at each of the 3 total visits required by the study. Each visit will occur at 14 weeks 
(+/- 2 weeks): 
 
Visit 1 
• 
The subject’s medical history will be gathered. This will include information regarding a 
subject’s height, weight, medications used, vitamin D levels, kidney, liver, and heart 
function.  
o For control subjects, the PI will confirm that the subjects do not have NF1 by 
family history and physical exam.  
• 
Questionnaires regarding pain and fatigue will be provided for the subject to review and 
answer. 
• 
Standard-of-care lab draws will continue to occur.   
• 
An additional 10 mL of blood will then be drawn for mitochondrial testing purposes.  

Title:  Evaluating mitochondrial dysfunction in patients with neurofibromatosis type 1 
PI:  Erika Santos Horta, MD 
 
 
Version #:  v3. 
Date:  5/18/2023  
Page 6 
 
 
Visit 2 
• 
Questionnaires regarding pain and fatigue will be provided for the subject to review and 
answer 
• 
Standard-of-care lab draws will continue to occur. An additional 10 mL of blood will then 
be drawn for mitochondrial testing purposes.  
Visit 3 
• 
Questionnaires regarding pain and fatigue will be provided for the subject to review and 
answer 
• 
Standard-of-care lab draws will continue to occur. An additional 10 mL of blood will then 
be drawn for mitochondrial testing purposes.  
 
 
Control Group 
NF1 Group 
 
At time of 
Consent 
Baseline/Visit 1  
Visit 2 (14 
weeks +/- 2 
weeks) 
Visit 3 (14 
weeks +/- 2 
weeks) 
Medical History 
 
X 
 
 
FACIT-F QoL 
 
X 
X 
X 
Numeric Pain 
Rating QoL 
 
X 
X 
X 
Research Lab – 
Blood 
X 
X 
X 
X 
SOC labs 
 
X 
X 
X 
 
 
Study Population 
This study will look to enroll 40 to 45 adults over 18 years old diagnosed with NF1 as well as  10 
to 15 adults over 18 years old without NF1 (the control group).   
 
Inclusion Criteria 
 
NF1 group 
• 
Over 18 years old 
• 
Diagnosed with NF1 
• 
Agreeable to participating in the study 
Control group 
• 
Over 18 years old 
• 
Agreeable to participating in the study 
• 
Not the first degree relative (biological parent, sibling, or child) of the NF1 patient 
who is in the NF1 group  

Title:  Evaluating mitochondrial dysfunction in patients with neurofibromatosis type 1 
PI:  Erika Santos Horta, MD 
 
 
Version #:  v3. 
Date:  5/18/2023  
Page 7 
 
Exclusion Criteria 
• 
NF1 group 
o Under  18 years old 
o Not agreeable to participating in the study 
• 
Control group 
o Under 18 years old 
o Diagnosed with NF1 
o The first degree relative (biological parent, sibling, or child) of an NF1 patient who 
is participating in the study  
Examples of recruitment methods include, but are not limited to the following:  
• 
Patients with NF1 at the UAMS Adult NF1 clinic will be invited to participate in the study 
during their regular clinic appointments. If the patient is interested in participating in the 
study, a Cancer Clinical Trial Office nurse will be called to consent the patient.   
• 
Spouses, friends, and non-relatives of NF1 patients who come to the UAMS Adult NF1 
Clinic will be invited to participate in the control arm of the study at the time of the patient 
appointment. If the non-patient is interested in participating in the study, a Cancer Clinical 
Trial Office nurse will be called to consent the control group volunteer.  They will then 
receive a single blood draw at the time of consent.   
 
Risks and Benefits 
Risk is minimal as this is not an intervention study and the only procedure is collection of 10 
mLs of blood. A blood draw can lead to discomfort, redness, bruising, or infection at the blood 
collection site.  
The questions being asked by the FACIT-F and Pain Scales may cause patients to become sad 
or upset.  
A risk to study subjects is the potential for loss of confidentiality of study data.   
Measures to protect the confidentiality of study data will be implemented as described in the 
Data Handling and Recordkeeping section below.  
There will be no direct benefits to the study participants; however, knowledge gained from the 
study could potentially benefit patients in the future. 
 
Data Handling and Recordkeeping 
The Principal Investigator will carefully monitor study procedures to protect the safety of 
research subjects, the quality of the data, and the integrity of the study.  
Paper Consents and paper forms will be stored at the Cancer Clinical Trials Office. A digital 
database for patient data entry will be developed by the Cancer Clinical Trials Office. The 
database will be housed on a UAMS-maintained server. All data will be coded with a unique 
identifying number upon entry into the database. The key to the code will be kept separately and 
maintained electronically on a password-protected computer. Only the PI and the study staff will 
have access to the key linking a patient’s name to their data.   

Title:  Evaluating mitochondrial dysfunction in patients with neurofibromatosis type 1 
PI:  Erika Santos Horta, MD 
 
 
Version #:  v3. 
Date:  5/18/2023  
Page 8 
 
At the conclusion of the study, the samples and data will be indefinitely stored in a repository for 
future use. The key linking the samples and data to a subject’s name will be retained indefinitely 
at the time of study closure in order to de-identify the data/samples.   
If any patient desires to have their blood sample destroyed at any time during or after 
conclusion of this study, patient data will be decoded, and the sample will be destroyed upon 
the subject’s request for withdrawal.   
 
Specimen Handling and Storage  
Blood samples will be collected from patients and controls during routine appointments. 
Samples will be given a unique identifying number, and then transported to Dr. Nukhet Aykin-
Burns’ laboratory where they will be tested and stored. A key linking the coded sample to the 
data will be maintained separately on a UAMS password-protected server. Transport will be 
done by Drs Nukhet Burns laboratory staff.  
 
If the patient sample volume is not completely used for this project, it will be retained for further 
study if patient indicates so in the consent. This sample might be used for future research to 
study the pathophysiology of neurofibromatosis. In the case that there is an opportunity to use 
the storage blood, we will decode data and enter in contact with patient to request their consent 
for the new project.  
 
Data Analysis 
XF Pro mito-stress test data will provide direct measurements of basal, nonmitochondrial, 
and maximum respiration, and we will use these data to calculate the mitochondrial basal 
respiration, ATP-linked respiration, reserve respiratory capacity, proton leakage, and coupling 
efficiency in PBMCs and platelets isolated from the control group once and from NF1 patients 
longitudinally (3 times). At the end of each run, we will also determine the cellular bioenergetics 
and metabolic plasticity (switch between oxidative phosphorylation and glycolysis) of the cells 
via plotting extracellular acidification rate versus oxygen consumption rate. The NF1 and healthy 
control groups' mitochondrial function and metabolic plasticity parameters will be compared in 
addition to longitudinal changes in these parameters for each NF1 patient. Linear regression 
analysis will be utilized to establish the relationship between coupling efficiency, respiratory 
capacity (ATP-linked, reserve capacity etc.) as well as metabolic plasticity and NF1 clinical 
phenotype and biochemical scores for fatigue, pain, CK, cardiac function, BMI, and liver 
function. Analysis of variance for repeated measures will also be used to analyze changes in 
these parameters over time by each group (NF1 patients before and after Vitamin D and/or KOS 
administration).   
 
This pilot study was designed to test the feasibility of our recruitment and implementation 
procedures and operational strategies. Preliminary data obtained from this pilot project will also 
be used to assess the variability of outcomes for power analysis of future larger studies. A 
biostatistician will be consulted during pilot data analysis and included in the team for statistical 
power calculations for future studies. 
 

Title:  Evaluating mitochondrial dysfunction in patients with neurofibromatosis type 1 
PI:  Erika Santos Horta, MD 
 
 
Version #:  v3. 
Date:  5/18/2023  
Page 9 
 
Ethical Considerations 
This study will be conducted in accordance with all applicable government regulations 
and University of Arkansas for Medical Sciences research policies and procedures. This 
protocol and any amendments will be submitted and approved by the IRB as required.   
No compensation will be given for patients or controls.  
The informed consent of each subject, using IRB-approved consent materials, will be obtained 
before that subject begins any study procedures. All subjects for this study will be provided a 
paper consent form describing this study in language understandable to the study population. 
Consent materials will provide sufficient information for subjects to make an informed decision 
about their participation in this study. The person obtaining consent will thoroughly explain what 
the subjects need to know about the study, including study requirements, study risks and 
benefits. The consent process will take place during their clinic visit in the exam room. The 
consent discussion will occur at the same day of the first blood sample. Participant privacy will 
be maintained and questions regarding participation will be answered.  No coercion or undue 
influence will be used in the consent process. This consent form must be signed by the subject, 
and the person obtaining the consent. The participant will receive a paper copy of the signed 
consent form, and the informed consent process will be documented in the research record.   
The consent process will be documented separately via a written note in the research or 
medical chart for each subject. 
 
Dissemination of Data 
Results of this project will be presented in Neurofibromatosis and Neuro-oncology symposium 
and Conferences, as published in neuro-oncology and metabolism journals.   
 
References 
1.  
Lin AL, Gutmann DH. Advances in the treatment of neurofibromatosis-associated 
tumours. Vol. 10, Nature Reviews Clinical Oncology. 2013.  
2.  
Uusitalo E. Neurofibromatosis Type 1: From Gene to Population and Cancer. 
AnnUnivTurku. 2018;(1339).  
3.  
Landry JP, Schertz KL, Chiang YJ, Bhalla AD, Yi M, Keung EZ, et al. Comparison 
of Cancer Prevalence in Patients with Neurofibromatosis Type 1 at an Academic 
Cancer Center vs in the General Population from 1985 to 2020. JAMA Netw 
Open. 2021;4(3).  
4.  
Tamura R. Current understanding of neurofibromatosis type 1, 2, and 
schwannomatosis. Vol. 22, International Journal of Molecular Sciences. 2021.  
5.  
Cichowski K, Jacks T. NF1 tumor suppressor gene function: Narrowing the GAP. 
Vol. 104, Cell. 2001.  
6.  
Ratner N, Miller SJ. A RASopathy gene commonly mutated in cancer: The 
neurofibromatosis type 1 tumour suppressor. Vol. 15, Nature Reviews Cancer. 
2015.  

Title:  Evaluating mitochondrial dysfunction in patients with neurofibromatosis type 1 
PI:  Erika Santos Horta, MD 
 
 
Version #:  v3. 
Date:  5/18/2023  
Page 10 
 
7.  
Gehart H, Kumpf S, Ittner A, Ricci R. MAPK signalling in cellular metabolism: 
Stress or wellness? Vol. 11, EMBO Reports. 2010.  
8.  
de Souza MLR, Jansen AK, Rodrigues LOC, Vilela DL de S, Kakehasi AM, 
Martins AS, et al. Increased resting metabolism in neurofibromatosis type 1. Clin 
Nutr ESPEN. 2019;32.  
9.  
Tong JJ, Schriner SE, McCleary D, Day BJ, Wallace DC. Life extension through 
neurofibromin mitochondrial regulation and antioxidant therapy for 
neurofibromatosis-1 in Drosophila melanogaster. Nat Genet. 2007;39(4).  
10.  Masgras I, Ciscato F, Brunati AM, Tibaldi E, Indraccolo S, Curtarello M, et al. 
Absence of Neurofibromin Induces an Oncogenic Metabolic Switch via 
Mitochondrial ERK-Mediated Phosphorylation of the Chaperone TRAP1. Cell 
Rep. 2017;18(3).  
11.  Botero V, Stanhope BA, Brown EB, Grenci EC, Boto T, Park SJ, et al. 
Neurofibromin regulates metabolic rate via neuronal mechanisms in Drosophila. 
Nat Commun. 2021;12(1).  
12.  Vasiljevski ER, Burns J, Bray P, Donlevy G, Mudge AJ, Jones KJ, et al. L-
carnitine supplementation for muscle weakness and fatigue in children with 
neurofibromatosis type 1: A Phase 2a clinical trial. Am J Med Genet Part A. 
2021;185(10).  
13.  Virmani MA, Cirulli M. The Role of L-Carnitine in Mitochondria, Prevention of 
Metabolic Inflexibility and Disease Initiation. Vol. 23, International Journal of 
Molecular Sciences. 2022.  
14.  Scharping NE, Rivadeneira DB, Menk A V., Vignali PDA, Ford BR, Rittenhouse 
NL, et al. Mitochondrial stress induced by continuous stimulation under hypoxia 
rapidly drives T cell exhaustion. Nat Immunol. 2021;22(2).  
15.  Beckermann KE, Dudzinski SO, Rathmell JC. Dysfunctional T cell metabolism in 
the tumor microenvironment. Vol. 35, Cytokine and Growth Factor Reviews. 2017.  
16.  Morrissey SM, Zhang F, Ding C, Montoya-Durango DE, Hu X, Yang C, et al. 
Tumor-derived exosomes drive immunosuppressive macrophages in a pre-
metastatic niche through glycolytic dominant metabolic reprogramming. Cell 
Metab. 2021;33(10).  
17.  Larkins E, Blumenthal GM, Chen H, He K, Agarwal R, Gieser G, et al. FDA 
approval: Alectinib for the treatment of metastatic, ALK-positive non-small cell 
lung cancer following crizotinib. Clin Cancer Res. 2016;  
18.  Kuhnke A, Burmester GR, Krauss S, Buttgereit F. Bioenergetics of immune cells 
to assess rheumatic disease activity and efficacy of glucocorticoid treatment. Ann 
Rheum Dis. 2003;62(2).  
19.  Garrabou G, Morén C, López S, Tobías E, Cardellach F, Miró Ò, et al. The effects 
of sepsis on mitochondria. J Infect Dis. 2012;205(3).  

Title:  Evaluating mitochondrial dysfunction in patients with neurofibromatosis type 1 
PI:  Erika Santos Horta, MD 
 
 
Version #:  v3. 
Date:  5/18/2023  
Page 11 
 
20.  Karamercan MA, Weiss SL, Villarroel JPP, Guan Y, Werlin E, Figueredo R, et al. 
Can peripheral blood mononuclear cells be used as a proxy for mitochondrial 
dysfunction in vital organs during hemorrhagic shock and resuscitation? Shock. 
2013;40(6).  
21.  Alfatni A, Riou M, Charles AL, Meyer A, Barnig C, Andres E, et al. Peripheral 
blood mononuclear cells and platelets mitochondrial dysfunction, oxidative stress, 
and circulating mtDNA in cardiovascular diseases. Vol. 9, Journal of Clinical 
Medicine. 2020.  
22.  Hartman ML, Shirihai OS, Holbrook M, Xu G, Kocherla M, Shah A, et al. Relation 
of mitochondrial oxygen consumption in peripheral blood mononuclear cells to 
vascular function in type 2 diabetes mellitus. Vasc Med (United Kingdom). 
2014;19(1).  
23.  Delbarba A, Abate G, Prandelli C, Marziano M, Buizza L, Arce Varas N, et al. 
Mitochondrial Alterations in Peripheral Mononuclear Blood Cells from Alzheimer’s 
Disease and Mild Cognitive Impairment Patients. Oxid Med Cell Longev. 
2016;2016.  
24.  Bergqvist C, Wolkenstein P. MEK inhibitors in RASopathies. Vol. 33, Current 
opinion in oncology. 2021.  
25.  Messiaen LM, Wimmer K. NF1 mutational spectrum. Monogr Hum Genet. 
2008;16.  
26.  Kurtz A, Lueth M, Kluwe L, Zhang T, Foster R, Mautner VF, et al. Somatic 
mitochondrial DNA mutations in neurofibromatosis type 1-associated tumors. Mol 
Cancer Res. 2004;2(8).  
27.  Roudebush M, Slabe T, Sundaram V, Hoppel CL, Golubic M, Stacey DW. 
Neurofibromin colocalizes with mitochondria in cultured cells. Exp Cell Res. 
1997;236(1).  
28.  Dard L, Bellance N, Lacombe D, Rossignol R. RAS signalling in energy 
metabolism and rare human diseases. Vol. 1859, Biochimica et Biophysica Acta - 
Bioenergetics. 2018.  
29.  Ripple MO, Kim N, Springett R. Acute mitochondrial inhibition by mitogen-
activated protein kinase/extracellular signal-regulated kinase kinase (MEK) 1/2 
inhibitors regulates proliferation. J Biol Chem. 2013;288(5).  
30.  Ling W, Krager K, Richardson KK, Warren AD, Ponte F, Aykin-Burns N, et al. 
Mitochondrial Sirt3 contributes to the bone loss caused by aging or estrogen 
deficiency. JCI Insight. 2021;6(10).  
31.  Koss B, Shields BD, Taylor EM, Storey AJ, Byrum SD, Gies AJ, et al. Epigenetic 
control of Cdkn2a.Arf protects tumor-infiltrating lymphocytes from metabolic 
exhaustion. Cancer Res. 2021;80(21).  
32.  Sridharan V, Aykin-Burns N, Tripathi P, Krager KJ, Sharma SK, Moros EG, et al. 

Title:  Evaluating mitochondrial dysfunction in patients with neurofibromatosis type 1 
PI:  Erika Santos Horta, MD 
 
 
Version #:  v3. 
Date:  5/18/2023  
Page 12 
 
Radiation-induced alterations in mitochondria of the rat heart. Radiat Res. 
2014;181(3).  
33.  Kim HN, Richardson KK, Krager KJ, Ling W, Simmons P, Allen AR, et al. 
Simulated galactic cosmic rays modify mitochondrial metabolism in osteoclasts, 
increase osteoclastogenesis and cause trabecular bone loss in mice. Int J Mol 
Sci. 2021;22(21).  
34.  Krager KJ, Pineda EN, Kharade S V., Kordsmeier M, Howard L, Breen PJ, et al. 
Tocotrienol-Rich Fraction from Rice Bran Demonstrates Potent Radiation 
Protection Activity. Evidence-based Complement Altern Med. 2015;2015.  
35.  Wang L, Fang B, Fujiwara T, Krager K, Gorantla A, Li C, et al. Deletion of 
ferroportin in murine myeloid cells increases iron accumulation and stimulates 
osteoclastogenesis in vitro and in vivo. J Biol Chem. 2018;293(24).  
36.  Alam S, Carter GS, Krager KJ, Li X, Lehmler HJ, Aykin-Burns N. Pcb11 
metabolite, 3,3’-dichlorobiphenyl-4-ol, exposure alters the expression of genes 
governing fatty acid metabolism in the absence of functional sirtuin 3: Examining 
the contribution of mnsod. Antioxidants. 2018;7(9).  
37.  Banerjee S, Melnyk SB, Krager KJ, Aykin-Burns N, McCullough SS, James LP, et 
al. Trifluoperazine inhibits acetaminophen-induced hepatotoxicity and hepatic 
reactive nitrogen formation in mice and in freshly isolated hepatocytes. Toxicol 
Reports. 2017;4.  
38.  Machado MO, Kang NYC, Tai F, Sambhi RDS, Berk M, Carvalho AF, et al. 
Measuring fatigue: a meta-review. Vol. 60, International Journal of Dermatology. 
2021.  
39.  Wolters PL, Martin S, Merker VL, Tonsgard JH, Solomon SE, Baldwin A, et al. 
Patient-reported outcomes of pain and physical functioning in neurofibromatosis 
clinical trials. Neurology. 2016;87(7).  
40.  Rocca C, De Francesco EM, Pasqua T, Granieri MC, De Bartolo A, Gallo Cantafio 
ME, et al. Mitochondrial Determinants of Anti-Cancer Drug-Induced Cardiotoxicity. 
Vol. 10, Biomedicines. 2022.