Evaluation of Newborn Screening for Diseases Using C5-OH as a Marker: Systematic Review of the Literature and Evaluation of 17 Years of C5-OH Screening in the Netherlands

In 2007, the Dutch newborn screening (NBS) program was expanded to include C5-OH as a marker to screen for three inborn errors of metabolism (IEMs): 3-methylcrotonyl-CoA carboxylase deficiency (3-MCCD), 3-hydroxy-3-methylglutaryl-CoA lyase deficiency (HMGCLD) and holocarboxylase synthetase deficiency (HLCSD). This study evaluates the effectiveness of C5-OH as an NBS marker by analyzing data from neonates screened in the Dutch NBS program from 2007 to 2023 and by reviewing the literature on various IEMs detected by an elevated NBS C5-OH concentration worldwide. Of the 126 neonates referred on the basis of elevated C5-OH concentrations in the Netherlands, 46 were true positive cases. No missed cases in the Netherlands have been reported so far, resulting in a positive predictive value of 38.3% and a negative predictive value of 100%. Strikingly, there was notable overlap between C5-OH concentrations of true and false positive cases. The systematic review included 58 articles and showed that C5-OH concentrations of patients with different IEMs reported in the literature were insufficiently distinctive to differentiate between these diseases. While C5-OH can be used to detect patients with 3-MCCD, HCLSD, and HMGCLD, its value is limited by the overlap of C5-OH concentrations between affected and unaffected neonates and among patients with different diseases. This emphasizes the need for improvement of the screening strategy and potentially the use of additional markers to increase its specificity.