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All sulfatases are post\u2010translationally activated by the formylglycine generating enzyme (FGE) which is deficient in multiple sulfatase deficiency (MSD), a neurodegenerative lysosomal storage disease. Historically, patients were presumed to be deficient of all sulfatase activities; however, a more nuanced relationship is emerging. Each sulfatase may differ in their degree of post\u2010translational modification by FGE, which may influence the phenotypic spectrum of MSD. Here, we evaluate if residual sulfatase activity and accumulating GAG patterns distinguish cases from controls and stratify clinical severity groups in MSD. We quantify sulfatase activities and GAG accumulation using three complementary methods in MSD participants. Sulfatases differed greatly in their tolerance of reduction in FGE\u2010mediated activation. Enzymes that degrade heparan sulfate (HS) demonstrated lower residual activities than those that act on other GAGs. Similarly, HS\u2010derived urinary GAG subspecies preferentially accumulated, distinguished cases from controls, and correlated with disease severity. Accumulation patterns of specific sulfatase substrates in MSD provide fundamental insights into sulfatase regulation and will serve as much\u2010needed biomakers for upcoming clinical trials. This work highlights that biomarker investigation of an ultra\u2010rare disease can simultaneously inform our understanding of fundamental biology and advance clinical trial readiness efforts.<\/jats:p>","DOI":"10.1002\/jimd.12688","type":"journal-article","created":{"date-parts":[[2023,10,23]],"date-time":"2023-10-23T17:19:55Z","timestamp":1698081595000},"page":"374-386","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":9,"title":["Biochemical signatures of disease severity in multiple sulfatase deficiency"],"prefix":"10.1002","volume":"47","author":[{"given":"Laura A.","family":"Adang","sequence":"first","affiliation":[{"name":"Division of Neurology The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania  Philadelphia Pennsylvania 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Philadelphia Pennsylvania USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nishitha R.","family":"Pillai","sequence":"additional","affiliation":[{"name":"Department of Pediatrics University of Minnesota  Minneapolis Minnesota USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paul J.","family":"Orchard","sequence":"additional","affiliation":[{"name":"Department of Pediatrics University of Minnesota  Minneapolis Minnesota USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mauricio","family":"De Castro","sequence":"additional","affiliation":[{"name":"Department of Pediatrics University of Mississippi Medical Center  Jackson Mississippi USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adeline","family":"Vanderver","sequence":"additional","affiliation":[{"name":"Division of Neurology The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania  Philadelphia Pennsylvania 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