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CPTII deficiency can also lead to increased levels of serum transaminases, CPK, creatinine, urea nitrogen, myoglobin, and ammonia [5, 14, 19], as well as to organic aciduria and increased urinary elimination of long-chain bicarboxylic acids [5]

However, managing severe side effects, such as nephrotoxicity, neurotoxicity, ototoxicity and myelosuppression, remains a challenge

Furthermore, it is of note that the changes of gene mRNA expression do not directly reflect the enzyme activities or protein functions, therefore, the regulatory mechanisms of L-carnitine at the transcriptional level still need further functional validation

For a focused review on TMAO formation and microbial steps, see this review (PMC)