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Creatine deficiency syndrome (CDS) comprises a group of inborn errors of creatine metabolism, characterized by a global developmental delay, intellectual disability and associated neurological (seizures, movement disorders, myopathy) and behavioral manifestions. CDS includes two creatine biosynthesis disorders; guanidinoacetate methyltransferase deficiency and L- Arginine: glycine amidinotransferase deficiency, as well as X-linked creatine transporter deficiency.
No HPO annotations are available for this condition.
Developmental delay, cognitive dysfunction, and intellectual disability are common to all three creatine deficiency disorders (CDDs). See for comparison of the three deficiencies; further details follow the table. Table 2. Creatine Deficiency Disorders: Comparison of Phenotypes by Select Features
The creatine deficiency disorders (CDDs) are inborn errors of creatine metabolism and transport that comprise:
Two creatine biosynthesis defects (both inherited in an autosomal recessive manner):
Guanidinoacetate methyltransferase (GAMT) deficiency
L-arginine:glycine amidinotransferase (AGAT) deficiency
No approved treatments are currently available for cerebral creatine deficiency syndrome. The disease remains an area of unmet medical need.
No clinical practice guidelines for creatine deficiency disorders (CDDs) have been published. Some of the references list management recommendations for GAMT and CRTR deficiencies .
To establish the extent of disease and needs in an individual diagnosed with a CDD, the evaluations summarized (if not performed as part of the evaluation that led to the diagnosis) are recommended.
Surveillance recommendations for CDDs are summarized in .
Table 9.
Recommended Surveillance for Individuals with Creatine Deficiency Disorders
System/Concern | Evaluation | Frequency
| Monitor developmental progress educational needs. | At each visit
No clinical trials have been registered for cerebral creatine deficiency syndrome.
11 publications have been identified in PubMed for cerebral creatine deficiency syndrome. Research spans Case Report / Case Series (36%), Diagnostic / Biomarker (18%), and Review / Meta-Analysis (18%).
Research Type | Count | % of Total |
|---|---|---|
Patient case studies | 4 | 36% |
Data assembled from 4 of 12 sources · Last updated Sep 20, 2026, 3:06 PM UTC
Patient Advocacy Groups (PAGs) provide support, resources, and community for patients and caregivers.
European rare disease database
Genetic and Rare Diseases Info Center
Common questions about cerebral creatine deficiency syndrome
Feature |
|---|
GAMT Deficiency1 |
|---|
AGAT Deficiency2 |
|---|
CRTR Deficiency3 |
|---|
Epilepsy | NR | — | — |
Behavior problems | Muscle weakness / | — | — |
Myopathy | NR | NR | — |
Movement disorder | NR | = all; = common; = infrequent; AGAT = L-arginine:glycine amidinotransferase; CRTR = creatine transporter; DD = developmental delay; GAMT = guanidinoacetate methyltransferase; NR = not reported 1. , 2. , 3. | — |
Source: GeneReviews — "Creatine Deficiency Disorders"
A CDD should be suspected in probands with the following clinical, biochemical, and imaging findings and family history.
Clinical findings
Source: GeneReviews — "Creatine Deficiency Disorders"
Disorders summarized in should be considered in individuals with partial creatine deficiency in the brain detected by 1H-MRS, who have normal concentrations of guanidinoacetate (GAA) in the urine, plasma, and CSF and a normal creatine-to-creatinine ratio in urine.
Table 3.
Disorders of Interest in the Differential Diagnosis of Creatine Deficiency Disorders
Gene | Disorder | MOI | Biochemical Features | Clinical Features
| P5CS deficiency1 (See Neurocutaneous Disorders due to Mitochondrial Proline Synthesis Defects.) | ARAD | Secondary (cerebral) creatine deficiency | Dysmorphic features, DD, spasticity, myopathy, slow growth
Source: GeneReviews — "Creatine Deficiency Disorders"
Biomarker and diagnostic research for cerebral creatine deficiency syndrome has been reported in the published literature.
Table 4.
Recommended Evaluations Following Initial Diagnosis in Individuals with Creatine Deficiency Disorders
System/Concern | Evaluation | Comment
| Neurologic eval | • Brain 1H-MRS to document creatine deficiency if not done as part of diagnosis
EEG if any clinical seizures or suspicion of seizures
| Developmental/neuropsychologic assessment | • Incl motor, adaptive, cognitive, speech-language eval
Eval for early intervention/ special education
Eval of cognitive functions w/objective tests to measure IQ
Movement
disorder1 | • Orthopedics/ physical medicine rehab/ PT/OT eval
Video documentation of mvmt disorder
| Incl assessment of:
Gross motor fine motor skills
Mobility, ADL, need for adaptive devices
Need for PT (to improve gross motor skills) /or OT (to improve fine motor skills)
| Neurobehavioral eval | For persons age 12 mos screening for:
Behavior concerns
Sleep disturbances
ADHD
Anxiety
Findings suggestive of ASD
Potential for
treatment-assoc
nephropathy | Baseline kidney function studies | • Blood urea
Source: GeneReviews — "Creatine Deficiency Disorders"
There are no current clinical trials for any of the CDDs. Some pharmacotherapies are being investigated in cell lines or animal models of CRTR deficiency:
Source: GeneReviews — "Creatine Deficiency Disorders"
View trials for cerebral creatine deficiency syndrome
| Monitor those w/seizures as clinically indicated.
Assess for new manifestations such as seizures, mvmt disorders, behavioral problems.
For those
undergoing
treatment of
low cerebral
creatine levels | Determination of cerebral creatine level by in vivo 1H-MRS | • For those w/GAMT or AGAT deficiency: to monitor cerebral creatine levels during creatine supplementation therapy
For those w/CRTR deficiency: to monitor cerebral creatine levels for assessment of treatment outcome
Assess kidney function (GFR) while on creatine supplementation therapy to detect possible creatine-assoc nephropathy in GAMT, AGAT, CRTR deficiencies. | Annually
For GAMT deficiency, assess:
Growth nutritional status;
Plasma GAA levels, plasma amino acids, ammonia, protein, albumin, pre-albumin levels.
| Every 3-6 mos
For AGAT deficiency, no surveillance labs needed |
For CRTR deficiency, assess plasma GAA levels plasma amino acids.1 | Every 3-6 mos
GAA = guanidinoacetate; GFR = glomerular filtration rate
1. High-dose arginine and glycine supplementation can result in increased GAA levels.
Source: GeneReviews — "Creatine Deficiency Disorders"
Estimated prevalence: Unknown (Unknown prevalence).
Testing and diagnosis research
2 |
18% |
Research summaries | 2 | 18% |
New treatment approaches | 2 | 18% |
Laboratory research | 1 | 9% |
Sharma S (2026). [PMID: 41792518](https://pubmed.ncbi.nlm.nih.gov/41792518/). *Indian J Pediatr*. [Diagnostic / Biomarker]
Tachikawa M (2026). [PMID: 41922264](https://pubmed.ncbi.nlm.nih.gov/41922264/). *Biol Pharm Bull*. [Review / Meta-Analysis]
Eda IR (2025). [PMID: 40955218](https://pubmed.ncbi.nlm.nih.gov/40955218/). *Cureus*. [Case Report / Case Series]
Schifino M (2025). [PMID: 40543028](https://pubmed.ncbi.nlm.nih.gov/40543028/). *Epilepsia Open*. [Case Report / Case Series]
Yuan X (2025). [PMID: 40892912](https://pubmed.ncbi.nlm.nih.gov/40892912/). *Proc Natl Acad Sci U S A*. [Basic Science / Preclinical]
Zhao TT (2025). [PMID: 40105081](https://pubmed.ncbi.nlm.nih.gov/40105081/). *Zhongguo Dang Dai Er Ke Za Zhi*. [Review / Meta-Analysis]
Wells C (2025). [PMID: 40338959](https://pubmed.ncbi.nlm.nih.gov/40338959/). *PLoS One*. [Gene Therapy / Novel Therapeutics]
Zhang Y (2024). [PMID: 39235923](https://pubmed.ncbi.nlm.nih.gov/39235923/). *Epileptic Disord*. [Case Report / Case Series]
Portales-Castillo I (2024). [PMID: 39544690](https://pubmed.ncbi.nlm.nih.gov/39544690/). *JIMD Rep*. [Case Report / Case Series]
Lee A (2024). [PMID: 39684202](https://pubmed.ncbi.nlm.nih.gov/39684202/). *Int J Mol Sci*. [Diagnostic / Biomarker]