di d f i id tblidisorders of amino acid metabolism...aminoacidopathies-most commonmost common...
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Di d f i id t b liDisorders of amino acid metabolism
http://plantandsoil.unl.edu/croptechnology2005/UserFiles/Image/siteImages/AminoAcidLG.gif
General comments on AA metabolisDisorders of aromatic AA metabolismDisorders of aromatic AA metabolism Disorders of branched chain AA metabolism Disorders of sulfur metabolism Disorders of propionate, B12 and biotinDisorders of propionate, B12 and biotin
metabolismUrea cycle disordersUrea cycle disordersOther disorders of AA metabolism
http://www.natuurlijkerwijs.com/english/b5e55bf0.gif
Energy stores
Energy store tissueamount
(g)energy
(kj) (kcal)Energy store tissue (g) (kj) (kcal)Glycogen liver 70 1176 280
Glycogen muscle 120 2016 480Glycogen muscle 120 2016 480
Glucose blood 20 336 80
Triacylglycerols fat 15 000 567 000 135 000acy g yce o s at 5 000 56 000 35 000
Proteins muscle 6000 100 800 24 000
http://www.studentconsult.com/content/default.cfm?ISBN=9780323053716
~ 400 g
http://uk.geocities.com/[email protected]/images/proteinoverview.png
Protein requirements
Protein intakeProtein intake
H T A hi A P iti Nit B l A d Wh Y CHow To Achieve A Positive Nitrogen Balance And Why You Care
By Fitness Atlantic Writer: Mike Westerdal
http://www.fitnessatlantic.com/how_achieve_nitrogen_balance.htm
http://www.mmi.mcgill.ca/mmimediasampler2002/images/Cianflone-60no5.gif
Patients with disorders of AA metabolismPatients with disorders of AA metabolism
sacharidy12%beta-oxidace a
OAU14%
puriny/pyrimidiny3%
AMK bez HPA
mitochondriální20%
%
AMK bez HPA18%
peroxisomální4%
HPA a PKU13%
lysosomální16%
ČR, 2005, n=127
incidence of aminoaciopathies for ČR ~ 1:300020 pacients with HPA/PKU~ 20 pacients with HPA/PKU
~ 30 pacients with other AA/OAU
Diseases of small molecules
usually dependent on exogenous supplymanifestation: (repeated) acute toxicity usuallymanifestation: (repeated) acute toxicity, usually with encephalopathy/comahepatopathy commonhepatopathy commoncommon disturbances in routine labs-ammonia, Astrup, ketone bodies, glycemia, uric acid...p, , g y ,symptoms develop due to specific type of food, fasting, catabolismchronic course possible (if toxicity low)usually good therapeutic response to diet and/or it ivitamins
Food and IEMs (small molecules)
(sub)acute toxicitymilk (lactose)-hepatopathysaccharose/fructose/sorbitol- hepatopathy and hypoglycemiahypoglycemia
excess protein- vomiting, lethargy, ( l di d icoma (urea cycle disorders, organic
acidurias))MCT oils- may be dangerous in MCAD deficiency
Patophysiology IEM
substrate
vedl.produkt<1500 Da
vedl.produkt
product
1 32
Aminoacidopathies-most commonAminoacidopathies most common mechanisms
Accumulation of AAAccumulation of AA
Ammonia accumulation
Carbon skeleton accumulations-organic acidsg
Product deficiency
Organic acidurias
several dozens of diseases
common feature: excretion of carboxylic acids (test-organic acids in urine)
orginin usually from carbon skeleton degradation of AAs (or saccharides or lipids)( p )
usually acute presentation- „intoxication type“
metabolic acidosis common (combination withmetabolic acidosis common (combination with hyperammonemia frequent)
Disorders of aromatic amino acid metabolism
PAH
http://www.chemie.fu-berlin.de/chemistry/bio/aminoacid/gif/phe.gif
PAH PhenylketonuriaPhenylketonuria
http://www.chemie.fu-berlin.de/chemistry/bio/aminoacid/gif/phe.gif
Mutations in PAH gene
zdroj: PAH mutation database
http://www.elmhurst.edu/~chm/vchembook/images/635pku.gif
http://www.bh4.org/biodefimages/Fig_bh4biox.gif
Untreated HPA/PKU
CZ 1:6,500, Turkey 1:3,000, very rare Finland, N Europe y , p1:15,0001-2% HPA secondary due to primary pterine defectslprimary pterine defectsl30% patients BH4 sensitivenewborn screeningguntreated HPA- mental retardation, typical mouse odour, light complexions eczemalight complexions, eczema, epilepsymaternal HPA-VCC, microcephaly a PMRmicrocephaly a PMR
http://www.dshs.state.tx.us/newborn/images/PKU_untreated.jpg
Cl i l di t t t t f PKUClassical dietary treatment of PKU
Prof.Horst Bickel
http://www.milupa-metabolics.com/produkte.php?sourceId=162&sysId=139
http://www.pkux.co.uk/wp-content/uploads/2009/05/horst-bickel-pku-diet.jpg
Sapropterinu (Kuvan)
http://www.mims.com/spldata/20080617_AF38711E-8873-4790-A92D-4D583E23FB89/kuvan-figure-02.jpg
LNAA in PKU treatment
http://www.funpecrp.com.br/gmr/year2006/vol1-5/gmr0182_full_text.htm
PKU- 3rd d PKU- 12the mo
http://www.pahdb.mcgill.ca/images/pku.gif&imgrefurl
PKU 3rd d PKU 12the mo
PAH Tyrosinemia 2y
http://www.chemie.fu-berlin.de/chemistry/bio/aminoacid/gif/phe.gif
T iTyrosine
http://meded.ucsd.edu/isp/1994/im-quiz/images/tyrosine.jpghttp://meded.ucsd.edu/isp/1994/im quiz/images/tyrosine.jpg
http://minimalpotential.files.wordpress.com/2007/11/730px-l-tyrosine-skeletal.png
Tyrosinemia type 2
hyperkeratossi herpetiformic keratitis
http://208.96.47.3/images/community/dermatlas/Tyrosinemia_type_2_2_041213.png
http://www.ijo.in/articles/2007/55/1/images/IndianJOphthalmol_2007_55_1_57_29497_2.jpg
Tyrosinemia type 2
very rareherpetiformicherpetiformic keratitispalmoplantarpalmoplantarhyperkeratoses with ulcersPMR, growth retardationdi t t t tdietary tretament
PAH Alkaptonuriap
http://www.chemie.fu-berlin.de/chemistry/bio/aminoacid/gif/phe.gif
</< td>
CoxarthrosisCoxarthrosisValvular involvementUrolithiasis
Harwa, 1500 př.n.l.
http://www.mja.com.au/public/issues/184_12_190606/sha20286_fm-1b.jpghttp://www.scielo.br/img/revistas/rbr/v46n5/a14fig02.jpghttp://bjo.bmj.com/content/vol83/issue6/images/large/98532.f1.jpeg
Alkaptonuria treatment artificalAlkaptonuria treatment-artifical block above the enzyme block
nitison (NTBC)
y
? what are the possible therapy complications?
http://www.natuurlijkerwijs.com/english/b4f4ca00.gif
PAH Tyrosinemia 1y
http://www.chemie.fu-berlin.de/chemistry/bio/aminoacid/gif/phe.gif
Tyrosinemia type IFumarylacetoacetaseFumarylacetoacetase deficiencyAcute manifestation in i finfancyHepatorenal involvement with acute hepaticwith acute hepatic dysfunction and Fanconi syndromeporfyric crises abdominalporfyric crises-abdominal crampsChronic- ci heatis and ca i i h iin cirhosimDiet, nitisone, liver transplantp
Tyrosinemia type I
Alkaptonuria a tyrosinemia 1 treatment
nitison (NTBC)
http://www.natuurlijkerwijs.com/english/b4f4ca00.gif
Disorders of branched chain amino acids
BCAA
http://www.agron.iastate.edu/courses/Agron317/Images/Branched_chain_aa.jpg
By Angie SchumacherBy Angie Schumacher
Amino Acids (BCAA's)Amino Acids (BCAA s) and your Workouts
http://www.wellsphere.com/vitamins-supplements-article/amino-acids-bcaa-s-and-your-workouts/9828
http://www.sportyshealth.com.au/images/T/87e9202fdfa362030ecb8bc0d5fd41bf.jpg
Leucinosis/maple syrup urine disease
http://www.childrenshospital.org/newenglandconsortium/NBS/MSUD/MSUD1.jpg
MSUDPeracute presentation in newborns, intermittent variantsintermittent variantsComa, dystonia-boxing cyclingboxing, cyclingmaple syrup odour
i i iacute crisis prevention and managementl t t t tlong term treatment-diet
http://losyoruguas.com/archivos/0686.gif
Psychomotor development-MSUD
Isovaleric acidemia
htt //i l /i ?i l htt // i t /i /http://images.google.com/imgres?imgurl=http://www.ivasupport.org/images/
http://img.medscape.com/fullsize/migrated/455/705/smj455705.fig1.gif
Isovaleric aciduria
IVA-CoA DH deficiency P t /i t itt tPeracute/intermittent courseComa with acidosis/ketonuria,
t f t dsweaty feet odourAcute crisis-eliminationLong term-diet, karnitine, glycineNewborn screening
http://www.arxmanstyle.com/wp-content/uploads/2009/01/sweaty-feet.jpg
Disorders of sulfur amino acid metabolism
Homocysteine
Homocysteine metabolism
CH3
methioninemethionine
CH3
cystathionineotherS compounds(C GSH T S)
3
(Cys,GSH, Tau, anorg. S)
Methionine cycle
THFMethionine
DMG
y
Gly
Ser
S-AdoMet
S Ad H
DMG
Methylene-THF
MGGly
S-AdoHcy
Homocysteine
Betaine
Methyl-THF
Cystathionine
Cysteine L-gamma-glutamylcysteineH2S
CysteinesulfinateGlutathione
Hypotaurine
Taurine
CysGlySO32- SO4
2-
Remethylation
THFMethionine
DMG
y
Gly
Ser
S-AdoMet
S Ad H
DMG
Methylene-THF
MGGly
S-AdoHcy
Homocysteine
Betaine
Methyl-THF
Cystathionine
Cysteine L-gamma-glutamylcysteineH2S
CysteinesulfinateGlutathione
Hypotaurine
Taurine
CysGlySO32- SO4
2-
Transsulfuration
THFMethionine
DMGGly
Ser
S-AdoMet
S Ad H
DMG
Methylene-THF
MGGly
S-AdoHcy
Homocysteine
Betaine
Methyl-THF
Cystathionine
Cysteine L-gamma-glutamylcysteineH2S
CysteinesulfinateGlutathione
Hypotaurine
Taurine
CysGlySO32- SO4
2-
Vitamins and Hcy metabolism
THFMethionine
DMG
y
Gly
Ser
S-AdoMet
S Ad H
DMG
Methylene-THF
MGGly
S-AdoHcy
Homocysteine
Betaine
Methyl-THF
Cystathionine
Cysteine L-gamma-glutamylcysteineH2SFolates
CysteinesulfinateGlutathione
B12
B2Hypotaurine
Taurine
CysGlySO32- SO4
2-
B2
B6
Two types of homocystinuriaTwo types of homocystinuria
CBS ÚDMP/KDDL: 16 patients
Remethylation
ÚDMP/KDDL:ÚDMP/KDDL: 4 patientsMTHFR, cblE
Cystine
1810 W ll t bl dd t1810 Wollaston- bladder stone (Greek cystos)- „cystic oxid“
1817 Marcet- the same compound also found in kidney stones, family y yoccurence (2 sibpairs)
http://www.acvs.org/AnimalOwners/HealthConditions/SmallAnimalTopics/Urolithiasis(UrinaryStones)/http://content.revolutionhealth.com/contentimages/images-image_popup-ww5rm52.jpg
Cystine
cystinuriacystinuria
History of cystinuria
1908 Garrod- one of 5 IEMs
incidence cca 1: 10 000
1994 SLCA1 gene 1999 SLC7A91994 SLCA1 gene, 1999 SLC7A9
hundreds of mutations
treatment: fluid intake, penicillamine, thioproninethiopronine
ticystine
http://www.kumc.edu/instruction/medicine/anatomy/histoweb/urinary/large/Ren13.JPG
Aim of treatment= increased solubility
merkaptopropionylglycine(thiopronine)
Cys-Cys
(thiopronine)
4-5 L fluids/dayalkalinizationalkalinization
Cystine
cystinosiscystinosis
Adult cystinosis
http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=gene&part=ctns
Cystinosisdefect of lysosomal transporter cystinosintransporter cystinosininfantile form: Fanconiho
dsyndrome-severe tubulopathyFTTFTTadultní forms: ocular involvement myopathymyopathy, hypothyreosisRx- cysteamine l ll d
Chemiosmotic coupling between cystinosin and the lysosomal H+-ATPase
locally and systematically
ATPase.
Disorders of propionate, cobalamin and biotin metabolism
Vitamin B12•complicated synthesis•exogenous intake needed•implied in only 2 reactionsp y•nutritional or endogenous deficiency is common
•pregnancy and lactationpregnancy and lactation•advanced age•GIT disorders
•long latent course•long latent course•anemia•demyelinizationpsychiatric manifestation•psychiatric manifestation
•treatment efficient and cheap
http://www.health-spy.com/hydroxob12.png
http://www.biochem.med.umich.edu/files/2008-student-photos/cracan.figure.jpg
http://images.google.com/imgres?imgurl=http://www.ncbi.nlm.nih.gov/bookshelf/picrender.fcgi
Peritoneal dialysis in PA
http://www.metagene.de/program/d.prg?id_d=18
Propionic acidemianewborn variant: episodes ofnewborn variant: episodes of ketoacidosis/hyperammonemia, coma, pancytopeniap y pmilder froms-repeated encefalopathic crises,FTTchronic problems: FTT, infections, variable CNS involvementinvolvementtherapy: IMTV restriction, gut sterilization, biotin in some patients, aggresive treatment of crises, gastrostomy,liver transplanttransplant
http://www.uchsc.edu/cbs/images/fig2.JPG
http://images.google.com/imgres?imgurl=http://www.ncbi.nlm.nih.gov/bookshelf/picrender.fcgi
Methylmalonic acidemianewborn variant: acute crisis with ketoacidosis, hyperammonemia and comaypmilder forms-repeated encephalopatic episodeschronic problems:chronic problems: nephropathy progressing in renal failure, variable CNS i l t ( i i tinvolvement (pacin picture partially deaf and mute), infections Candida sp.treatment: IMTV restriction, gut sterilization, in some pateints B12, aggresivní p , ggtreatment of acute episodes
http://images.google.com/imgres?imgurl=http://www.toby-churchill.com/files/images/lynn5.jpg
http://www.biochem.med.umich.edu/files/2008-student-photos/cracan.figure.jpg
Biotinidase deficiency
http://cme.medscape.com/viewarticle/432565_3
Biotinidase deficiencyVarious degree of BTDVarious degree of BTD deficiencyimpaired breakdown of pbiocytin and thus biotin incorporation
lti l b lmultiple carboxylase deficiencyeczema seizureseczema, seizures, PMRmiraculous responsemiraculous response to biotin administration
http://www.rug.nl/umcg/faculteit/disciplinegroepen/kindergeneeskunde/liverdigestivemetabolicdiseases/enzyme/images/biotinidase-grafiek.jpg
Urea cycle disorders
Ammoniaamonnia cationt
normal level 50-70 µmol/lµmol/l
somnolence above cca 150 µmol/l150 µmol/l
coma above 300-400 l/lµmol/l
Hyperammonemia is medical emergency
Vigility test
Why do patients with organic acidurias exhibit frequently elevated ammonia blood levels?
rinaryy
nitro
Urinary nitrogen excretion ogen
eMetabolite g 24 h* % total
xcreti
Urea 30 86
Ammonia ion 0.7 2.8ion.Creatinine 1.0-1.8 4-5
U i id 0 5 1 0 2 3Uric acid 0.5-1.0 2-3
http://www.studentconsult.com/content/default.cfm?ISBN=9780323053716
UCD- frequencyUCD frequency
OTC-clinical variability
Lethality of OTC
Scylla and Charibda
http://images.rxlist.com/images/rxlist/ammonul2.gif
Monitoring of substrateMonitoring of substrate restriction
Tolerance
Dietaryrecords Analyte(s)
Within range
Analyte low/low intake
Analyte high/ high intake
Analyte high/low intakerange low intake high intakelow intake
Other disorders of amino acid metabolism
Glutaric aciduria type 1Glutaric aciduria type 1
http://images.google.com/imgres?imgurl=http://upload.wikimedia.org/wikipedia/commons/
GlutarylCoA DHGlutarylCoA DH deficiency—glutarate, 3-OH-glutarate
l tiaccumulationneurotoxicity, basal ganglia involvementganglia involvement, dystonia, PMRíeasy intracranial ybleedingdown-the-staircase coursecoursediet (Lys, Trp), aggresive prevention of catabolismprevention of catabolismnewborn screening
www.medscape.com/viewarticle/501097_2
Prolidase deficiencyabnormal recycling of Pro into collagen-urinary loss of yiminodipeptides secondary immune defectsdefectsulcers and typical facial appearancePMR, splenomegaly, bone changes, mikrocytic anemiaytherapy local, systemic proline administrationadministration
http://dermatology.cdlib.org/127/case_presentations/prolidase/2.jpg
Hyperornithinemia
OAT deficiencyl t t 3 d 4thlate onset 3rd-4th decade-night blindnessblindnessgyrate atrophy of retinaretinatreatment with pyridoxine and dietarypyridoxine and dietary restriction of Orn
http://www.ncbi.nlm.nih.gov/books/bookres.fcgi/gnd/OAT.gif
Nonketotic hyperglycinemiaglycine cleaveage system deficiencyl t d f d bl delevated csf and blood
glycinesometimes prenatalsometimes prenatal manifestation, typical onset early after birthsevere axial hypotoniasevere axial hypotonia and peripheral hypertonusi t t bl iintractable seizures, hypsarytmietherapy inefficient: pyNMDA receptor block
A i id thi h iAminoacidopathies-mechanisms
Amino acid accumulationAmino acid accumulation
Ammonia accumulation
Carbon skeleton accumulation- organic acids
Product deficiency
Summary aminoacidopathiesSummary aminoacidopathies
G f b t 50 di dGroup of about 50 disorders
Mechanisms: varying toxicity and metabolite concentration
subgroup organic acidurias
subgroup hyperammonemias
Clinical presentation highly variable
Diagnossis by special assays
Treatment usually available and efficientTreatment usually available and efficient
Prenatal diagnosis usually possible