ATP synthase protein 8, also known as MT-ATP8, is a mitochondrially encoded protein that forms an essential component of the F-type ATP synthase complex (Complex V). This complex is responsible for the final step of oxidative phosphorylation in the electron transport chain, which is critical for cellular energy production . The recombinant version of Pongo abelii MT-ATP8 has been developed to facilitate research into mitochondrial function and energy metabolism, with specific applications in evolutionary biology, comparative mitochondrial studies, and potential therapeutic research.
The Pongo abelii MT-ATP8 protein consists of 68 amino acids and belongs to the transmembrane F0 portion of the ATP synthase complex. This subunit contributes to the proton channel functionality of the ATP synthase, allowing positively charged ions (protons) to flow across the inner mitochondrial membrane, thereby enabling ATP production .
The MT-ATP8 protein is a hydrophobic membrane protein that forms part of the F0 complex of ATP synthase. In the context of ATP synthase structure, MT-ATP8 (also referred to as subunit A6L in some species) is one of the components that anchors the stator stalk in the mitochondrial membrane . This structural role is critical for preventing futile rotation of ATPase subunits relative to the rotor during coupled ATP synthesis and hydrolysis.
While the specific three-dimensional structure of Pongo abelii MT-ATP8 has not been fully resolved, modeling based on homologous proteins suggests it forms a transmembrane 4-α-bundle structure, similar to other members of this protein family .
MT-ATP8 serves as an integral component of the F0 region of the ATP synthase complex. This complex consists of two main structural domains: the F1 catalytic domain that synthesizes ATP, and the F0 membrane domain that facilitates proton translocation across the inner mitochondrial membrane .
The MT-ATP8 protein specifically contributes to the stator stalk functionality, which anchors the ATP synthase in the membrane and prevents unnecessary rotation during ATP synthesis. This stabilization is essential for the efficient coupling of proton flow to ATP production .
The MT-ATP8 gene is encoded in the mitochondrial genome, and its sequence differs between metazoa, plants, and fungi . This divergence makes comparative studies of MT-ATP8 from different species, including Pongo abelii, valuable for understanding evolutionary relationships and the adaptation of energy metabolism across different organisms.
Recombinant Pongo abelii MT-ATP8 protein is typically produced using E. coli expression systems. The protein is expressed with an N-terminal histidine tag to facilitate purification through affinity chromatography . The use of bacterial expression systems allows for the production of significant quantities of the protein for research applications.
After expression, the recombinant protein undergoes purification processes to ensure high purity. According to product specifications, the purified protein typically has a purity greater than 90% as determined by SDS-PAGE analysis . This level of purity is essential for reliable research applications.
Recombinant Pongo abelii MT-ATP8 serves as a valuable tool for studying mitochondrial function and energy metabolism. The protein can be used in biochemical assays to investigate ATP synthase activity, proton transport mechanisms, and the structural organization of the ATP synthase complex.
The availability of recombinant MT-ATP8 from Pongo abelii facilitates comparative studies between different species. Such research can provide insights into evolutionary relationships and adaptations in mitochondrial energy production systems across different organisms .
Recent research on mitochondrial genes, including MT-ATP8, has explored allotopic expression as a potential approach for treating mitochondrial disorders. Allotopic expression involves re-engineering mitochondrial genes to be expressed from the nucleus and transported into the mitochondria . While the specific application to Pongo abelii MT-ATP8 has not been extensively documented, studies in mouse models have demonstrated the feasibility of this approach for the ATP8 gene, which could inform future research with primate MT-ATP8 proteins .
For optimal results, the following reconstitution guidelines are recommended:
Briefly centrifuge the vial prior to opening to bring contents to the bottom
Reconstitute in deionized sterile water to a concentration of 0.1-1.0 mg/mL
Add 5-50% glycerol (final concentration) for long-term storage
The default final concentration of glycerol is typically 50%
The recombinant protein is typically provided in a Tris/PBS-based buffer containing 6% trehalose at pH 8.0 . This formulation helps maintain protein stability during storage.
The study of MT-ATP8 has significant implications for understanding and potentially treating mitochondrial disorders. Mutations in mitochondrial genes, including MT-ATP8, have been associated with various neurodegenerative and cardiovascular conditions such as mitochondrial complex V deficiency, Leber's hereditary optic neuropathy (LHON), and other mitochondrial encephalomyopathies .
Research on allotopic expression of ATP8 in mouse models suggests promising approaches for addressing mitochondrial dysfunction . Similar techniques could potentially be applied to primate MT-ATP8, including the Pongo abelii variant, to develop novel therapies for mitochondrial disorders.
Comparative studies of MT-ATP8 across different primate species, including Pongo abelii, can contribute to our understanding of primate evolution and the adaptation of energy metabolism systems. Such research could reveal how variations in mitochondrial proteins have contributed to species-specific adaptations in energy production and utilization.
KEGG: pon:808474
STRING: 9601.ENSPPYP00000023443
MT-ATP8 (ATP synthase protein 8) is a mitochondrial DNA-encoded protein that functions as a subunit of the ATP synthase complex (also known as Complex V). This protein, also called A6L or F-ATPase subunit 8, plays a critical role in the formation and stability of the ATP synthase complex, particularly in the assembly of the F0 sector that is embedded in the inner mitochondrial membrane. The protein is essential for proton translocation across the membrane, which drives ATP synthesis through oxidative phosphorylation. In Pongo abelii (Sumatran orangutan), MT-ATP8 consists of 68 amino acids and is highly hydrophobic, consistent with its membrane-embedded localization .
The MT-ATP8 protein is evolutionarily conserved among primates, though with some species-specific variations. The Pongo abelii MT-ATP8 amino acid sequence (MPQLNTTTWPTIITPMLLALFLITQLKLLNSHLHPPTPPKFTKPKLHAKPWGPKWTKVYLPHSLPPQY) shares high homology with the human counterpart, particularly in functional domains involved in ATP synthase assembly. This conservation reflects the protein's critical role in mitochondrial energy production. Comparative analysis between human and orangutan MT-ATP8 provides insights into evolutionary adaptations in mitochondrial function across primate species. Differences in specific amino acid residues may contribute to species-specific adaptations in bioenergetics and metabolic efficiency .
MT-ATP8 and MT-ATP6 genes are located in the mitochondrial genome with a partially overlapping reading frame. This overlapping structure is conserved across many species including humans and other primates. Both genes encode essential components of the ATP synthase complex, with MT-ATP8 encoding subunit 8 (A6L) and MT-ATP6 encoding subunit α. Due to their genomic proximity and functional relationship in the same protein complex, mutations affecting one gene can sometimes impact the other. This genomic arrangement has implications for the co-evolution of these genes and the regulation of their expression. The overlapping nature of these genes also has significant consequences for understanding mitochondrial disorders, as pathogenic variants can potentially affect both proteins simultaneously .
For optimal reconstitution of lyophilized Recombinant Pongo abelii MT-ATP8, follow these methodological steps:
Briefly centrifuge the vial containing lyophilized protein to bring contents to the bottom before opening.
Reconstitute the protein in deionized sterile water to achieve a concentration between 0.1-1.0 mg/mL.
For long-term storage, add glycerol to a final concentration of 5-50% (with 50% being optimal for most applications).
Aliquot the reconstituted protein to minimize freeze-thaw cycles.
Store working aliquots at 4°C for up to one week.
For extended storage, keep at -20°C or preferably -80°C.
The protein is typically provided in a Tris/PBS-based buffer with 6% Trehalose at pH 8.0, which helps maintain stability. This methodology ensures maximum protein activity and stability for subsequent experimental applications .
Verifying the functional activity of recombinant MT-ATP8 requires several complementary approaches:
ATP Synthase Assembly Assay: Incorporate the recombinant MT-ATP8 into membrane-reconstituted systems and assess its ability to facilitate proper assembly of the ATP synthase complex using blue native PAGE and immunoblotting techniques.
Proton Translocation Measurement: Utilize pH-sensitive fluorescent probes (such as ACMA or pyranine) in liposome-reconstituted systems containing recombinant MT-ATP8 to measure proton movement across membranes.
Binding Partner Interaction Analysis: Perform co-immunoprecipitation or surface plasmon resonance to verify interactions with other ATP synthase subunits, particularly with MT-ATP6.
Complementation Studies: In cellular models with MT-ATP8 deficiency or downregulation, introduce the recombinant protein and measure restoration of ATP synthesis capacity.
Structural Integrity Assessment: Use circular dichroism spectroscopy to confirm proper protein folding, particularly the alpha-helical content expected in the transmembrane domains.
These methodological approaches provide comprehensive assessment of both structural and functional properties of the recombinant protein, ensuring its biological relevance in experimental systems .
The choice between His-tagged and untagged versions of recombinant MT-ATP8 depends on specific research applications:
His-tagged MT-ATP8 is preferred for:
Protein purification using affinity chromatography (Ni-NTA columns)
Protein-protein interaction studies requiring pull-down assays
Immunodetection experiments when specific MT-ATP8 antibodies are unavailable
Structural studies requiring highly purified protein
Proof-of-concept studies where protein quantification is critical
Untagged MT-ATP8 is more suitable for:
Functional studies where the tag might interfere with protein activity
Assembly studies of ATP synthase complex
Experiments mimicking physiological conditions
Studies of protein integration into biological membranes
Therapeutic development research requiring native protein structure
When using His-tagged versions, researchers should consider potential interference with protein folding or function, particularly for small proteins like MT-ATP8 (68 amino acids). Control experiments comparing tagged and untagged versions are recommended to validate that the tag does not alter functional properties in the specific experimental system being used .
Pathogenic variants in MT-ATP8 contribute to mitochondrial disorders through multiple mechanisms:
Bioenergetic Dysfunction: Mutations disrupt ATP synthase assembly or function, reducing ATP production capacity and creating cellular energy deficits. This particularly affects high-energy demanding tissues such as the central nervous system, muscle, eyes, and heart.
Heteroplasmy Effects: The variable load of mutant mitochondrial DNA in different tissues contributes to the phenotypic heterogeneity. Higher mutational loads typically correlate with more severe clinical manifestations, though variability exists even among individuals with similar mutation levels.
Developmental Impact: Early-onset cases (infantile and pediatric) demonstrate how MT-ATP8 dysfunction can severely affect developmental processes, particularly in neurological development, resulting in ataxia, cognitive delays, and motor impairments.
Tissue-Specific Manifestations: Recent clinical data from 111 patients shows that MT-ATP8 defects predominantly affect the central nervous system (93%), followed by muscle (75%), eyes (46%), and heart (18%), reflecting the varying energy requirements and mitochondrial capacity across tissues.
Overlapping Gene Effects: Due to the overlapping genomic arrangement with MT-ATP6, mutations can potentially affect both genes simultaneously, complicating the clinical picture and contributing to syndromes like NARP (Neuropathy, Ataxia, and Retinitis Pigmentosa) and Leigh Syndrome.
Understanding these pathogenic mechanisms is crucial for developing potential therapeutic approaches, though the heterogeneity of clinical presentations creates challenges for treatment development .
Several experimental models provide valuable insights into MT-ATP8 function, each with specific advantages for different research questions:
Cellular Models:
Transmitochondrial Cybrid Models: Created by fusing ρ0 cells (lacking mtDNA) with patient-derived platelets or mitochondria, these maintain the nuclear background while varying mitochondrial genotype. Ideal for studying heteroplasmy effects and bioenergetic consequences of MT-ATP8 mutations.
iPSC-Derived Models: Patient-specific induced pluripotent stem cells differentiated into neurons, cardiomyocytes, or other affected cell types allow tissue-specific study of MT-ATP8 dysfunction in relevant cellular backgrounds.
Biochemical Models:
Reconstituted Membrane Systems: Purified recombinant MT-ATP8 incorporated into liposomes with other ATP synthase components allows precise biophysical measurements of proton translocation and ATP synthesis.
Isolated Mitochondria Assays: Utilizing mitochondria isolated from various sources with manipulated levels of MT-ATP8 enables direct measurement of respiratory chain function and ATP production.
Animal Models:
Mouse Models: Though challenging due to differences in mitochondrial genetics, heteroplasmic mouse models carrying MT-ATP8 mutations can recapitulate aspects of human disease.
Drosophila Models: The simpler mitochondrial system of fruit flies allows exploration of fundamental MT-ATP8 functions and genetic interactions.
The choice of model should be guided by the specific research question, with composite approaches often providing the most comprehensive insights into both physiological function and pathological mechanisms .
Studying the complex interactions between nuclear-encoded factors and MT-ATP8 requires multifaceted methodological approaches:
Proximity Labeling Proteomics: Techniques such as BioID or APEX2 fused to MT-ATP8 can identify proximal interacting proteins in the native mitochondrial environment, revealing transient or stable interactions during assembly.
Conditional Knockdown Systems: Implementing inducible knockdown of specific nuclear-encoded assembly factors in combination with MT-ATP8 variants allows temporal analysis of assembly dependencies.
Cryo-EM Structural Analysis: Comparing structures of ATP synthase complexes with normal and mutant MT-ATP8, or at different assembly stages, provides atomic-level insights into interaction interfaces.
Quantitative Interaction Proteomics: SILAC or TMT-based quantitative proteomics comparing wildtype versus mutant MT-ATP8 interactomes can reveal differential binding partners.
Genetic Complementation Assays: Expressing nuclear-encoded factors in cells with MT-ATP8 deficiencies to assess rescue of phenotypes identifies functional interactions.
Live-Cell Imaging: Using split fluorescent protein systems to visualize MT-ATP8 interactions with nuclear-encoded assembly factors in real-time during mitochondrial biogenesis.
Mitochondrial Translation Modulation: Employing techniques that specifically regulate mitochondrial translation to alter the stoichiometry between MT-ATP8 and nuclear-encoded components.
These approaches collectively provide a comprehensive understanding of the spatiotemporal dynamics of interactions between MT-ATP8 and its nuclear-encoded partners, which is essential for understanding both physiological assembly processes and pathological mechanisms .
Recombinant MT-ATP8 offers multiple applications in developing advanced diagnostic tools for mitochondrial disorders:
Standard Reference Material: Highly purified recombinant MT-ATP8 serves as a calibration standard for mass spectrometry-based quantitative proteomics, allowing precise measurement of endogenous MT-ATP8 levels in patient samples.
Antibody Development: Using recombinant Pongo abelii MT-ATP8 as an immunogen for generating specific antibodies enables development of immunoassays for detecting altered MT-ATP8 levels or abnormal localization in patient-derived samples.
Functional Assay Development: Reconstituted systems incorporating recombinant MT-ATP8 provide reference standards for functional assays measuring ATP synthase activity in diagnostic settings.
Variant Classification System: Recombinant protein harboring various MT-ATP8 mutations enables creation of a functional classification system to determine the pathogenicity of novel variants identified in patients.
Biomarker Correlation Studies: Combining quantitative measurements of MT-ATP8 with clinical biomarkers (such as lactic acid, alanine, or citrulline levels) helps establish correlation patterns for improved diagnostic accuracy.
The international study of 111 patients with MT-ATP6/8 deficiency revealed that early-onset patients often show increased lactic acid and alanine levels, while reduced plasma citrulline was observed in some newborn screening. These findings suggest potential biomarkers that could be incorporated into diagnostic assays using recombinant MT-ATP8 as reference material .
Recent basic research on MT-ATP8 has yielded several promising translational insights:
Heteroplasmy Modulation: Understanding the molecular mechanisms controlling mitochondrial DNA segregation and heteroplasmy could lead to approaches for selectively reducing mutant MT-ATP8 load in affected tissues.
Metabolic Bypass Strategies: Research into the precise bioenergetic consequences of MT-ATP8 dysfunction has identified alternative metabolic pathways that could be therapeutically enhanced to compensate for ATP synthesis deficits.
Small Molecule Stabilizers: Structural studies of MT-ATP8's role in ATP synthase assembly have suggested potential binding sites for small molecules that could stabilize partially assembled complexes containing mutant MT-ATP8.
Biomarker Development: The identification of citrulline as a potential biomarker and therapeutic supplement represents a direct translation from basic research to clinical application. Six patients with reduced plasma citrulline levels who received citrulline supplementation showed reduced metabolic crises and disease severity.
Natural History Data Application: The comprehensive analysis of 111 patients with MT-ATP6/8 deficiency provides critical data for clinical trial design, revealing that CNS involvement (93%), followed by muscle involvement (75%), represent the most relevant systems for therapeutic targeting and outcome measurement.
Survival Analysis Insights: The relatively low mortality rate (only 8% of patients not alive at follow-up) despite high morbidity suggests that quality of life measures may be more appropriate endpoints for clinical trials than survival.
These translational insights demonstrate how fundamental research on MT-ATP8 provides foundation for developing potential therapeutic approaches, biomarkers, and appropriate clinical trial design for mitochondrial disorders .
The significant heterogeneity of MT-ATP8-related disorders presents several methodological challenges for clinical research:
Stratification Approaches:
Recent clinical data demonstrates the value of age-at-onset stratification (infantile <1 year, pediatric 1-12 years, late onset >12 years) for predicting clinical course and outcome measures. This approach revealed distinct phenotypic patterns, with infantile onset patients (44% of cases) showing more severe presentations including cognitive/language delays (74%) and motor delays (81%).
Endpoint Selection Challenges:
The variable progression and multi-system involvement necessitate carefully selected endpoints. The international study of 111 patients revealed that while CNS involvement is nearly universal (93%), specific manifestations vary widely, requiring composite outcome measures that capture the multidimensional nature of disease progression.
Biomarker Identification:
The observed metabolic variations across patient subgroups require tailored biomarker approaches. Increased lactic acid was identified as a universal biomarker, while alanine elevation was more specific to early-onset cases (49%), and reduced citrulline represents a potential early biomarker in newborn screening.
Genetic Complexity:
The varying loads of heteroplasmy and the overlapping nature of MT-ATP6/8 genes necessitate precise genetic characterization in clinical studies. The three most common pathogenic variants (m.8993T>G, m.8993T>C, and m.9185T>C) showed different clinical patterns, requiring mutation-specific analysis in therapeutic development.
Long-term Follow-up Requirements:
The relatively high survival rate (92% alive at last follow-up) despite significant morbidity indicates that long-term studies are necessary to adequately assess disease progression and treatment efficacy.
Personalized Therapeutic Approaches:
The heterogeneous presentations suggest that therapeutic approaches may need personalization based on specific mutations, heteroplasmy levels, age at onset, and affected tissue systems.
This complex heterogeneity requires sophisticated clinical trial designs with careful patient stratification, composite outcome measures, and sufficient statistical power to detect treatment effects across diverse manifestations .
MT-ATP8 presents several technical challenges during recombinant expression and purification:
Hydrophobicity and Membrane Integration:
Challenge: The highly hydrophobic nature of MT-ATP8 can cause protein aggregation and inclusion body formation.
Solution: Utilize specialized E. coli strains designed for membrane protein expression (C41(DE3), C43(DE3)); incorporate solubility-enhancing fusion partners (SUMO, thioredoxin); optimize expression at lower temperatures (16-18°C) to slow folding and reduce aggregation.
Protein Stability Issues:
Challenge: MT-ATP8 can be unstable outside its native membrane environment.
Solution: Include appropriate detergents (DDM, LMNG) or lipids during purification; maintain glycerol (50%) in storage buffers; use trehalose (6%) as a stabilizing agent; avoid repeated freeze-thaw cycles by storing smaller working aliquots.
Proper Folding Verification:
Challenge: Confirming correct folding of this small (68aa) hydrophobic protein.
Solution: Employ circular dichroism to verify alpha-helical content; perform limited proteolysis to assess structural integrity; conduct functional reconstitution assays with other ATP synthase components.
Yield Limitations:
Challenge: Low expression yields common with mitochondrial proteins.
Solution: Optimize codon usage for E. coli; use controlled induction systems (like IPTG concentration gradient); explore baculovirus expression systems for higher yields of properly folded protein.
Purification Complexity:
Challenge: Difficult separation from bacterial membrane components.
Solution: Implement two-step purification protocols combining affinity chromatography (via His-tag) with size exclusion or ion exchange chromatography; consider on-column refolding techniques during affinity purification.
These methodological approaches have been optimized for the recombinant Pongo abelii MT-ATP8 protein currently available for research applications, ensuring maximum functionality for experimental use .
When troubleshooting experimental challenges in MT-ATP8 research, particularly in ATP synthase assembly studies, consider this methodological approach:
Diagnostic Indicators: Reduced co-localization with other ATP synthase components; protein precipitation during reconstitution
Troubleshooting Approach:
Adjust lipid composition to better mimic mitochondrial inner membrane (higher cardiolipin content)
Optimize protein-to-lipid ratios (typically start with 1:100 and titrate)
Try different reconstitution methods (detergent dialysis vs. direct incorporation)
Verify protein solubility before reconstitution using dynamic light scattering
Include small amounts (0.1-0.5%) of the initial solubilization detergent in the reconstitution buffer
Diagnostic Indicators: Assembly appears normal but functional assays show no difference between wildtype and mutant/absent MT-ATP8
Troubleshooting Approach:
Confirm assay sensitivity using known ATP synthase inhibitors as positive controls
Verify complete assembly using multiple detection methods (BN-PAGE, immunoblotting, EM)
Assess proton gradient formation independently of ATP synthesis
Examine subtle kinetic parameters rather than endpoint measurements
Consider the need for additional factors present in mitochondria but absent in reconstituted systems
Diagnostic Indicators: Effects observed with purified components differ from cellular experiments
Troubleshooting Approach:
Verify protein modifications (phosphorylation, acetylation) that may occur in cells but not in vitro
Examine temporal aspects of assembly that may not be captured in endpoint assays
Consider the role of mitochondrial membrane potential in facilitating proper interactions
Assess potential compensation mechanisms active in cellular systems
Implement pulse-chase experimental designs to distinguish assembly from stability effects
These methodological approaches provide systematic strategies for addressing common challenges in MT-ATP8 research, enhancing experimental reliability and interpretation .
Multiple analytical techniques provide complementary insights into MT-ATP8 structure and function:
Structural Analysis Techniques:
Cryo-Electron Microscopy (Cryo-EM):
Methodology: Sample vitrification followed by high-resolution imaging
Application: Resolves the position of MT-ATP8 within the assembled ATP synthase complex
Advantage: Can visualize the protein in its native membrane environment without crystallization
Resolution: Can achieve near-atomic resolution (2-4Å) for well-ordered regions
Nuclear Magnetic Resonance (NMR) Spectroscopy:
Methodology: Isotopic labeling (15N, 13C) of recombinant MT-ATP8 in membrane mimetics
Application: Determines dynamic properties and secondary structure elements
Advantage: Provides atomic-level data on protein flexibility and interactions in solution
Key Parameter: Best for analyzing specific domains or peptide fragments due to size limitations
Cross-linking Mass Spectrometry (XL-MS):
Methodology: Chemical cross-linking followed by proteolytic digestion and MS analysis
Application: Maps interaction interfaces between MT-ATP8 and other subunits
Advantage: Captures transient interactions in native environments
Data Analysis: Requires specialized software for cross-link identification and structural modeling
Functional Analysis Techniques:
Site-Directed Fluorescence Labeling:
Methodology: Strategic placement of fluorescent probes on recombinant MT-ATP8
Application: Monitors conformational changes during catalytic cycle
Advantage: Real-time measurements in reconstituted systems
Controls: Requires careful validation that labels don't disrupt function
Hydrogen-Deuterium Exchange Mass Spectrometry (HDX-MS):
Methodology: Measures rate of hydrogen/deuterium exchange in protein backbone
Application: Identifies protected regions and conformational dynamics
Advantage: Can analyze proteins in native-like environments without size limitations
Resolution: Provides peptide-level resolution of structural changes
Patch-Clamp Electrophysiology of Reconstituted Systems:
Methodology: Electrical measurements of proteoliposomes containing MT-ATP8 and partners
Application: Directly measures proton translocation function
Advantage: Quantitative assessment of ion transport activity
Technical Challenge: Requires specialized equipment and high technical expertise
These methodological approaches provide comprehensive structural and functional insights when applied in complementary fashion, enabling researchers to connect MT-ATP8 structure with its essential role in ATP synthase function .
| Sign/symptom | Infantile Onset (<1y) (%) | Pediatric Onset (1-12y) (%) | Late Onset (>12y) (%) |
|---|---|---|---|
| Central/peripheral nervous system | |||
| Ataxia | 28 | 89 | 85 |
| Cognitive delay/language delay | 74 | 72 | 20 |
| Dysmetria | 2 | 3 | 10 |
| Dystonia | 14 | 19 | 5 |
| Hypotonia | 67 | 50 | 15 |
| Lethargy | 30 | 14 | 15 |
| Motor delay/motor regression | 81 | 61 | 20 |
| Movement disorders | 30 | 64 | 50 |
| Neuropathy | 14 | 36 | 70 |
| Nystagmus | 16 | 14 | 20 |
| Seizures | 47 | 22 | 5 |
| Muscle | |||
| Dysphagia | 32 | 26 | 16 |
| Dysphonia | 10 | 34 | 21 |
| Muscle pain | 0 | 9 | 47 |
| Ptosis | 20 | 20 | 21 |
| Weakness/fatigue | 59 | 83 | 95 |
| Eyes | |||
| Ophthalmoplegia | 21 | 12 | 32 |
| Optic atrophy | 10 | 18 | 37 |
| Retinal hypopigmentation | 0 | 6 | 5 |
| Retinitis pigmentosa | 10 | 15 | 42 |
| Visual defects | 38 | 24 | 63 |
| Heart | |||
| Arrhythmia | 3 | 3 | 11 |
| Cardiomyopathy | 29 | 9 | 5 |
| Heart attack/acute arrhythmia | 0 | 3 | 5 |
| Heart failure | 8 | 3 | 0 |
| Hypertrophic cardiomyopathy | 21 | 0 | 0 |