_| L Couse Code: BCH 204 Course Title: Medical Biochemistry Topics: i. Carbohydrate Metabolism . Glycolysis and Intermediary Metabolism isorders of Carbohydrate Metaboli CARBOHYDRATE METABOLISM Carbohydrates are the most abundant biomolecules on Earth. Each year, photosynthesis conv erts more than 100 billion metric tons of CO, and H0 into cellulose and other plant products Certain carbohydrates (sugar and starch) are a dietary staple in most parts of the world, and t he oxidation of carbohydrates is the central energy-yielding pathway in most non-photosynthe tic cells. Carbohydrate polymers (also called glycans) serve as structural and protective eleme nts in the cell walls of baeteria and plants and in the connective tissues of animals. Other car bohydrate polymers lubricate skeletal joints and participate in recognition and adhesion betw een cells. Complex carbohydrate polymers covalently attached to proteins or lipids act as sign als that determine the intracellular destination or metabolic fate of these hybrid molecules, cal led glycoconjugates. Carbohydrates are polyhydroxy aldehydes or ketones, or substances that yield such compounds on hydrolysis. Many, but not all, carbohydrates have the empirical for mula (CH;0)n; some also contain nitrogen, phosphorus, or sulfur. Carbohydrates are the most abundant macromolecules on our planet, in part because of the p lant carbohydrates cellulose and starch, both composed of multiple conjugated glucose mole cules. Cellulose is an important structural element of plant cell walls. Animals lack enzymes t hat can break down the cellulose into smaller glucose molecules, but they can break down sta rch into smaller glucose molecules. Animals also have glycogen, another carbohydrate compo sed of multiple conjugated glucose molecules. Carbohydrates occupy an important place in metabolism because of their roles in energy prod uction and various biosynthetic pathways. Starch is the main source of energy in most popul ations; before it can be absorbed, it must be broken down. The hydrolysis of starch is catalyze dby enzymes known as amylases, which occur in the saliva and the pancreatic juice. The am ylases of animal origin are called a-amylases to distinguish them from the B-amylases of pla nits, which differ in their point of attack on the starch molecule. The B-amylases are exoamyla ses that nip of f maltose units from the ends of the amylose and amylopectin molecules, wher eas the c-amylases are endoamylases and catalyze the breakdown of bonds occuring in the i nterior of the molecules. The first products of the action of the c-amylases are the dextrins, w “] : rT_| L hich are progressively degraded into smaller and smaller units. The final product consists mai nly of maltose together with some small branched-chain oligosaccharides. A separate enzym e produced in the intestine is required to hydrolyze the a-1:6 bonds of amylopectin. The dietar y carbohydrates also include sucrose and lactose. Specific disaccharides that convert theses ugars into their constituent monosaccharides are present in the brush border of the intestinal epithelial cells Carbohydrates are divided into three major groups based on their structures: 1. Simple sugars (monosaccharides and disaccharides): Monosaccharides, or simple sugars, consist of a single polyhydroxy aldehyde or ketone unit. The most abundant monosaccharide in nature is the six-carbon sugar D-glucose, sometimes referred to as dextrose. Monasacchari des of four or more carbons tend to have cyclic structures Monosaccharides include; glucose, fructose, galactose, mannose e.t.c. Disaccharides include; Sucrose, Lactose, Maltose e.t.c. 2. Oligosaccharides: Oligosaccharides consist of short chains of monosaccharide units, or re sidues, joined by characteristic linkages called glycosidic bonds. The most abundant are the d isaccharides, with two monosaccharide units. Typical is suerose (cane sugar), which consists of the sixcarbon sugars D-glucose and D-fructose. All common monosaccharides and disacce harides have names ending with the suffix “ose.” In cells, most oligosaccharides consisting o f three or more units do not occur as free entities but are joined to nonsugar molecules (lipids or proteins) in glycoconjugates. 3. Complex carbohydrates (Polysaccharides): The polysaccharides are sugar polymers contai ning more than 20 or so monosaccharide units; some have hundreds or thousands of units. S ome polysaccharides, such as cellulose, are linear chains; others, such as glycogen, are brane hed. Both glycogen and cellulose consist of recurring units of D-glucose, but they differ in the type of glycosidic linkage and consequently have strikingly different properties and biological roles 4, Glycoconjugates: These are modified forms of glucose covalently attached to either protei nis (glycoproteins) or lipids (glycolipids), which participate in important functions, such asim munity, and as components of cell membranes. Monosaccharides and Disaccharides The simplest of the carbohydrates, the monosaccharides, are either aldehydes or ketones with two or more hydroxyl groups; the six-carbon monosaccharides glucose and fructose have five hydroxyl groups. Many of the catbon atoms to which hydroxyl groups are attached are chiral © enters, which give rise to the many sugar stereoisomers found in nature. Stereoisomerism in ugars is biologically significant because the enzymes that act on sugars are strictly stereospe cific, typically preferring one stereoisomer to another by three or more orders of magnitude, as “] , rT_| L reflected in Km values or binding constants. Itis as difficult to fit the wrong sugar stereoisom er into an enzymes binding site as it is to put your left glove on your right hand We begin by describing the families of monosaccharides with backbones of three to seven ca tbons~ their structure and stereoi someric forms, and the means of representing their three-di mensional structures on paper. We then discuss several chemical reactions of the carbonyl gr oups of monosaccharides. One such reaction, the addition of a hydroxyl group from within th e same molecule, generates cyclic forms having four or more backbone carbons (the forms th at predominate in aqueous solution). This ring closure creates a new chiral center, adding furt her stereochemical complexity to this class of compounds. The nomenclature for unambiguo usly specifying the configuration about each carbon atom in a cyclic form and the means of r epresenting these structures on paper are therefore described in some detail; this information will be useful as we discuss the metabolism of monosaccharides. The Two Families of Monosaccharides Are Aldoses and Ketoses Monosaccharides are colorless, crystalline solids that are freely soluble in water but insoluble in nonpolar solvents. Most have a sweet taste. The backbones of common monosaccharides are unbranched carbon chains in which all the carbon atoms are linked by single bonds. In thi s open-chain form, one of the carbon atoms is double-bonded to an oxygen atom to form aca rbonyl group; each of the other carbon atoms has a hydroxyl group. If the carbonyl group is at an end of the carbon chain (that is, in an aldehyde group) the monosaccharide is an aldose; if the carbonyl group is at any other position (in a ketone group) the monosaccharide is a ketos e. The simplest monosaccharides are the two three-carbon trioses: glyceraldehyde, an aldotrio. se, and dihydroxyacetone, a ketotriose. Monosaccharides with four, five, six, and seven carbon atoms in their backbones are called, re spectively, tetroses, pentoses, hexoses, and heptoses. There are aldoses and ketoses of each of these chain lengths: aldotetroses and ketotetroses, aldopentoses and ketopentoses, and so on. The hexoses, which include the aldohexose D-glucose and the ketohexose D-fructose, are t he most common monosaccharides in nature—the products of photosynthesis, and key inter mediates in the central energy-yielding reaction sequence in most organisms. The aldopentos es D-ribose and 2-deoxy-D-ribose, are components of nucleotides and nucleic acids The Asymmetric Centers of Monosaccharides All the monosacchatides except dihydroxyacetone contain one or more asymmetric (chiral) ca bon atoms and thus accur in optically active isomeric forms. The simplest aldose, glyceralde hyde, contains one chiral center (the middle carbon atom) and therefore has two different opti cal isomers, or enantiomers. NB. One of the two enantiomers of glyceraldehyde is, by convention, designated the D isomer, ‘the other the L isomer. As for other biomolecules with chiral centers, the absolute configuratio “| ,_| L ns of sugars are known from x-ray crystallography. In general, a molecule with n chiral centers can have 2» stereoisomers. Glyceraldehyde has 2° = 2; the aldohexoses, with four chiral centers, have 2*= 16. The stereoisomers of monosaccha tides of each carbon-chain length can be divided into two groups that differ in the configurati on about the chiral center most distant from the carbonyl carbon. Those in which the configur ation at this reference carbon is the same as that of D-glyceraldehyde are designated D isome rs, and those with the same configuration as L-gly ceraldehyde are L isomers. In other words, when the hydroxyl group on the reference carbon is on the right (dextro) in a projection formmul a that has the carbonyl carbon at the top, the sugars the D isomer, when on the left (levo), iti s the Lisomer. Of the 16 possible aldohexoses, eight are D forms and eight are L. Most of the hexoses of living organisms are D isomers. Why D isomers? An interesting and unanswered q uestion. Recall that all of the amino acids found in protein are exclusively one of two possible stereoisomers, L. The basis for this initial preference for one isomer during evolution is also u nknown; however, once one isomer had been selected, it was likely that evolving enzymes wou Id retain their preference for that stereoisomer. The Cyclic Structures of Monosaccharides For simplicity, we have thus far represented the structures of aldoses and ketoses as straight- chain molecules. In fact, in aqueous solution, aldotetroses and all monosaccharides with five or more carbon atoms in the backbone occur predominantly as cyclic (ring) structures in whic h the carbonyl group has formed a covalent bond with the oxygen of a hydroxyl group along t he chain. The formation of these ring structures is the result of a general reaction between alc ohols and aldehydes or ketones to form derivatives called hemiacetals or hemniketals. Two mo lecules of an alcohol can add toa carbony! carbon; the product of the first addition is a hemia cetal (for addition to an aldose) or a hemiketal (for addition toa ketose). If the -OH and carts onyl groups are from the same molecule, a five-or six-membered ring results. Addition of the second molecule of alcohol produces the full acetal or ketal, and the bond formed is a glycosi diclinkage. When the two molecules that react are both monosaccharides, the acetal or ketal formed is a disaccharide."Three carbons Tire carbonr : KP KP KP " \ ‘ on wot non sofa \ wton whe | | oe aor be pH won won Lon ton lon lon von iron out buon von yon aon i Ca] tome mc crtons Wee AP NR KE KAKO on nota on nota ton ota ton ota Ce ta ele ate cle de ele ole ton on ton on moto not Hota ton on aon on on on to lon bron baow bon buon bayou le bale le owHOH HOH CH ,OH ‘p-Brythrulese| Five carbons Six carbons HOH CH,OH os Hon HOG_OH n—d—ou n—l_on buon énon | D-Pricose ‘b-Fructose | cu,o CHO qu.on Lo to eo || Lon noha | Hota (| not noha wynon | | oon lon én.088 duo dro [D3yiuioss | |p Sorben p-Tagatowe D-Ketones Figure 1. Aldoses and Ketoses Metabolism of imple Sugars The Greek word "sakcharon” means sugar, and we use the word saccharide to denote a sugar. Simple sugars are monosaccharides, such as glucose, galactose or fructose; the disaccharide s include lactose or milk sugar (galactose and glucose), suctose or table sugar (glucose and f ructose), and maltose (glucose and glucose). Sucrase and lactase are enzymes that break do wn sucrose and lactose into their monosaccharides, respectivelys. Many adults are unable to metabolize lactose (ie., they are lactose intolerant) usually because of diminished levels of th e enzyme lactase. Certain bacteria in the colon use lactose as a source of fuel and, in the proc ess, generate methane (CH4) and hydrogen gas (H2), which cause discomfort in the gut and t he embarrassing problem of flatulence. “d ‘ i. ; év,oH En,on Ho-CcH, ©. CH,OH skn ORD 2 # on on oH Fructose Glucose Galactose cH,on CH,0n 0 Sucrose on (Glucose-fructose) cH,OH CH,on ch,on Ho 5 Lactose (Galactose-glucose) cH,oH cH,on O. oH Maltose (Glucose-glucose) & Figure 2. Structures of some simple sugars The metabolic fate of these sugars can be quite diverse. Glucose, galactose, and fructose ent er glycolysis through different routes. Glucose becomes glucose 6-phosphate by an ATP-depe ndent reaction, using hexokinases. Galactose enters through the Leloir pathway, in which gala ctokinase uses ATP to generate galactose 1-phosphate, which is converted to glucose 1-phos phate and, subsequently, to glucose 6 phosphate by the enzymes galactose-1-P-uridy| transfer ase and phosphoglucomutase, respectively. In the liver, glucose 6;phosphate can be converte dto glucose, whereas, in other tissues, it is metabolized through glycolysis. The conversion of galactose to glucose 6-phosphate is slower than the rate by which glucose becomes glucose “] ; rTA osshae In proliferating cells, the replacement of glucose with galactose in vitro results we the galactose preferentially entering the pentose phosphate pathway (PPP) because mitochon drial oxidative phosphorylation provides ATP and the need for ribose 5-phosphate provided by the PPP is important for proliferation. In cells with mitochondrial oxidative phosphorylation de fects, galactose metabolism through glycolysis is too slow to generate enough ATP to meet m etabolic demands, resulting in metabolic catastrophe and cell death. Mitochondrial biologists use galactose sensitivity to determine whether a genetic mutation or pharmacologic inhibitor i s suppressing oxidative phosphorylation cnacrose [ cmscronnase Galactose 1-phosphate % UP.Glucose ure uop.ctucose \ "7a, GALAcTose 1,pHospHate vaornos \" (ODP-GLALncTose Gmipve TRansremase PHORVUASE oe UDP-Galactose - Glucose L-phosphate. <——® GLYCOGEN HEXOKINASE ‘cLucose Glucose phosphate © ——» priospHare PATHWAY ATP > ADP GLYCOLYSIS Figure 3. Galactose catabolism occurs through the Leloir pathway. Galactokinase converts ga lactose into galactose 1-phosphate, which subsequently becomes glucose 1-phosphate, whic han either be stored as glycogen or enter glycolysis by being converted into glucase 6-phosp hate. Fructoseis primarily metabolized by the liver and, to a lesser extent, by the small intestine and kidney. The first step is the phosphorylation of fructose to fructose 1-phosphate by fructokina se. Subsequently, fructose 1-phos phate is cleaved into glyceraldehyde and dihydroxyacetone phosphate by a specific fructose 1-phosphate aldolase B. Glyceraldehyde is then phosphoryla ted to glyceraldehyde 3-phosphate, a glycolytic intermediate, by triose kinase. The glycolytic i ntermediates generated can either proceed through glycolysis and its subsidiary biosynthetic r eactions, including generation of fatty acids or storage as glycogen. At first glance, it seems t hat fructose metabolism eventually mirrors glucose metabolism; however, fructose enters glyc “] 5 [_| L alysis after the important regulatory step of PFK1 in glycolysis. cLycoceN ‘Glucose 1-phosphate } prosenoctucomuase ‘Glucose 6-phosphate —» @Phospho- coro 9 ADP ate Fructose 6-phosphate F-1,6-0Pase ty Pr FRUCTOSE Fructose 1-phosphate Fructose 1,6-bisphosphate FRUCTOKINASE MDOLASE MIDOLASEA PENTOSE SHUNT hyceradehyde Ditydroxjacetone Drossboutoiace.2 Fructose 1,6 cose 6 shosohtase Ho phasphate Posoolucose omar ‘phosphate Frutoce .6-bechemhstare 40 isohosphate ce "Ho phoebe (2) Glyceraldehyde 3-phosphate y= Dihydroxyacatone phosphate 2a" + 28 2 NADH 4 2H ‘cigs | (2) 3-Phosph oi (2) 2Phosph nee (2) 1.2-aiphoephoglvearate a [agra ee eoraeeae 2H0 Glucortjenesis po. Poosoeatyarto kinase 2Ho hoalycrrate Prosohogtycerte mae oatycerate add ano (2) Phospheencipyruvate pte Kinase rroronoenierat catorsinace yrte carbone apr Figure 7. Opposing Pathways of Glycolysis and Gluconeogenesis. “] 18_| L Citric Acid or Tricarboxylic Acid (TCA) or Kreb’s Cycle Some cells obtain energy (ATP) by fermentation, breaking down glucose in the absence of ox ygen. For most eukaryotic cells and many bacteria, which live under aerobic conditions and o xidize their organic fuels to carbon dioxide and water, glycolysis is but the first stage in the co mplete oxidation of glucose. Rather than being reduced to lactate, ethanol, or some other ferm entation product, the pyruvate produced by glycolysis is further oxidized to H,0 and C0,. This aerobic phase of catabolism is called respiration. In the broader physiological or macroscopic sense, respiration refers to a multicellular organism's uptake of Q, and release of C02, Bioche mists and cell biologists, however, use the term in a narrower sense to refer to the molecular pr ocesses by which cells consume Q, and produce CO,~processes more precisely termed cellul ar respiration. Cellular respiration occurs in three major stages; 1. In the first, organic fuel molecules—glucose, fatty acids, and some amino acids—are oxidize d to yield two-carbon fragments in the form of the acety| group of acetyl-coenzyme A (acety!- CoA). 1. Ih the second stage, the acetyl groups are fed into the citric acid eycle, which enzymatically oxidizes them to CO; the energy released is conserved in the reduced electron carriers NADH and FADH, 3. In the third stage of respiration, these reduced coenzymes are themselves oxidized, giving u p protons (H') and electrons. The electrons are transferred to O2~the final electron acceptor— via a chain of electron-carrying molecules known as the respiratory chain. In the course of ele ctton transfer, the large amount of energy released is conserved in the form of ATR, by a proce ss called oxidative phosphorylation. Respiration is mare complex than glycolysis.sen content rcaycon O Civigconet Teta cond ° wall... SS een Me cnsn a as ate SET onatenctate crate strate eto Sieees 0-1-0 HO-¢-coo” —_repoaitonedinisectrate Contensaton in neat 4-00, cx—coo” BAe! = . i" innont a. ~fnsnte ‘itricacideycle tee \ n° mate 7 Serysiogenase p peste oe a ‘te=coo7 Sebo $00" le nconieate upton i Seiden step - 2 = Fumarate 01 — J —_ paar Phtraup oie 0 c “artery ehchintare foe Nn coo a met ‘Sete docarbonfation by satay arerion ‘uaonsequene. nee Suciote Coo : et m cer dao- re ° ¢-8008 Suoptratetevel Bo ° osreyot Sr SuccnptCON freee scparpenctne phowphonohydide bond of ‘ibonylom adjacent abon. Ereerar. Figure 8. Reactions of the Citric Acid Cycle Pentose Phosphate Pathway of Glucose Oxidation In most animal tissues, the major catabolic fate of glucose 6-phosphate is glycolytic breakdo wn to pyruvate, much of which is then oxidized via the citric acid cycle, ultimately leading to t he formation of ATP. Glucose 6-phosphate does have other catabolic fates, however, which le ad to specialized products needed by the cell. Of particular importance in some tissues is the oxidation of glucose 6-phosphate to pentose phosphates by the pentose phosphate pathway {also called the phosphogluconate pathway or the hexose monophosphate pathway. In this o xidative pathway, NADP* is the electron acceptor, yielding NADPH. Rapidly dividing cells, such as those of bone marrow, skin, and intestinal mucosa, and those of tumors, use the pentose ri bose S-phosphate to make RNA, DNA, and such coenzymes as ATP, NADH, FADH», and coenzy me A. In other tis sues, the essential product of the pentose phosphate pathway is not the pent “] » rT_| L oses but the electron donor NADPH, needed for reductive biosynthesis or to counter the dama ging effects of oxygen radicals. Tissues that carry out extensive fatty acid synthesis (liver, adi pose, lactating mammary gland) or very active synthesis of cholesterol and steroid hormones (liver, adrenal glands, gonads) require the NADPH provided by this pathway. Erythrocytes and the cells of the lens and comea are directly exposed to oxygen and thus to the damaging free radicals generated by oxygen. By maintaining a reducing atmosphere (a high ratio of NADPH t o NADP* and a high ratio of reduced to oxidized glutathione), such cells can prevent or undo o xidative damage to proteins, lipids, and other sensitive molecules. In erythrocytes, the NADPH produced by the pentose phosphate pathway is so important in preventing oxidative damage that a genetic defect in glucose 6-phosphate dehydrogenase, the first enzyme of the pathway, can have seriaus medical consequences. The Oxidative Phase Produces Pentose Phosphates and NADPH The first reaction of the pentose phosphate pathway is the oxidation of glucose 6:phosphate by glucose 6;phosphate dehydrogenase (G6PD) to form 6-phosphoglucono-d-lactone, an intra molecular ester. NADP* is the electron acceptor, and the overall equilibrium lies far in the direc tion of NADPH formation. The lactones hydrolyzed to the free acid 6phosphogluconate by a specific lactonase, then 6-phosphogluconate undergoes oxidation and decarboxylation by 6p hosphogluconate dehydrogenase to form the ketopentose, ribulose 5-phosphate; the reaction generates a second molecule of NADPH. (This ribulose 5-phosphate is important in the regula tion of glycolysis and gluconeogenesis. Phosphopentose isomerase converts ribulose Sphos phate to its aldose isomer, ribose 5-phosphate. In some tissues, the pentose phosphate pathw ay ends at this point, and its overall equation is; Glucose 6-phosphate + 2NADP+*H20 Ribose 5-phosphate + C02 + 2NADPH + 2H+.The net result is the production of NADPH, a reductant for biosynthetic reactions, and ribase 5-pho sphate, a precursor for nucleotide synthesis| conosphe wer | ghee Scone are soe me cphmphoucnt wacom fe Satecmes [Sm or S41 cr von von eine S-phosphate oboe Srphosphate ea Figure 9. Oxidative Reactions of the Pentose Phosphate Pathway. The Non-Oxidative Phase Recycles Pentose Phosphates to Glucocose-6-phosphates In tissues that require primarily NADPH, the pentose phosphates produced in the oxidative ph ase of the pathway are recycled into glucose 6-phosphate. In this nonoxidative phase, ribulos e Sphosphate is first epimerized to xylulose S-phosphate ction HoH c=0 ceo I i H—¢—on Ho—c—H i hore i H—C—OH — S-phowhate HC —OH i epimerase i cH,aroy- coro} Ribulose Xylulose 5-phosphate S-phosphate Then, in a series of rearrangements of the carbon skeletons, six five-carbon sugar phosphates are converted to five six-carbon sugar phosphates, completing the cycle and allowing continu ed oxidation of glucose 6-phosphate with production of NADPH. Continued recycling leads ult “] » rT_| L imately to the conversion of glucose 6;phosphate to six C02. Two enzymes unique to the pent ose phosphate pathway act in these interconversions of sugars: transketolase and transaldol ase. Transketolase catalyzes the transfer of a two-carbon fragment from a ketose donor to an aldose acceptor. In its first appearance in the pentose phosphate pathway, transketolase trans fers C-1 and C-2 of xylulose Sphosphate to ribose 5-phosphate, forming the seven-carbon pro duct sedoheptulose 7-phosphate. The remaining three-carbon fragment from xylulose is glyce raldehyde 3.phosphate. Next, transaldolase catalyzes a reaction similar to the aldolase reactio nof glycolysis: a three-carbon fragment is removed from sedoheptulose 7-phosphate and con densed with glyceraldehyde 3-phosphate, forming fructose 6phosphate and the tetrose erythr ose 4-phosphate. Now transketolase acts again, forming fructose 6-phosphate and glyceralde hyde phosphate from erythrose 4-phosphate and xylulose 5-phosphate. Two molecules of g lyceraldehyde 3-phosphate formed by two iterations of these reactions can be converted toa molecule of fructose 1 6-bisphosphate as in gluconeogenesis, and finally FBPase-1 and phos phohexose isomerase convert fructose 1,6-bisphosphate to glucose 6-phosphate. Overall, six pentose phosphates have been converted to five hexose phosphates—the cycleis now compl ete.“] Pentove Phosphate pathway chucoge-«-» lotacose-s-phesphate aaoen gf tsbrdroocnese *-Dhosphogluconala ctons © lctecomelactonere 6-Phosphogluconate o-phosphogteconate naoon pA Phrarogenase Ribulose-S-phosphate Ribose-S-phosphate Xylulocs Yy Clyceraldehyde 2-phoephate + Sedoheptulose 7-phosphate Ributese-S-phosphate phosphate Frensoldolare Fructose 6-phosphate + Exythrose 4-phosphate Olpcotysts Oxidative phase Non-oxidative phase Xylulose- 5 phosphate me S-phosphate + | S-phosphate ot. Figure 10. Pentose Phosphate Pathway orien_| L Disorders of Carbohydrate Metabolism Carbohydrate metabolism disorders are errors of metabolism that affect the catabolism and anabolism of carbohydrates. The inability to effectively use metabolites of carbohydrates accounts for th e majority of these disorders Carbohydrates play both a structural role in the cell, as elements of nucleic acids and glycopro teins, anda metabolic role, as a major energy source. There are several key clues to the diagn osis of an inherited disorder of carbohydrate metabolism, but in most cases, the differential di agnosis is quite broad. Glucose is the primary carbohydrate energy source, and hypoglycemia isa common presenting symptom among the various disorders. When not being used by the body, glucose is stored in the muscles and liver as glycogen, and thus hepatomegaly or hypot onia and muscle weakness may also be seen. As with other biochemical pathways, the bioma tker of choice to measure for either diagnosis or follow up for disorders of carbohydrate meta bolismn depends on which pathway has the blockade. In most cases, this involves determining the enzymatic activity of the dysfunctional enzyme or measuring the concentration of metabo lites that accumulate due to the obstruction. This chapter describes the clinical picture, bioma tkers for diagnosis, and treatment for disorders of carbohydrate metabolism including galacto semia, glycogen storage diseases (GSD), and disorders of fructose metabolism: 1. Galactosemia Galactosemia is a family of autosomal recessive disorders in which the metabolism of the sugar galactose is disrupted. There are three forms of galactosemia, depending on which enzymein the Leloir pathway of galactose metabolism is nonfunctiona |. Classic galactosemia is the most common of the three disorders, and it is caused by mutation in the gene for the galactose-1-phosphate uridylyltransferase (GALT) enzy me. Defects in this enzyme result in the accumulation of galactitol and galactose-1-phosphate metabolit es, 1 Galactokinase (GALK) defciency is a much rater form of galactosemia, and its caused by mutation in the gene that encodes the enzyme GALK, causing an accumulation of galactose in the blood and tissue s. The third typeof galactosemia is termed epimerase deficiency galactosemia and is caused by rrutati on in the gene for the enzyme UDP-galactose-4epimerase (GALE). These patients also accumulate gala ctose and galactose- 1-phosphate in erythrocytes as well as high levels of UDP-galactose. Clinical Presentation: Patients with classic galactosemia are asymptomatic at birth, but develop life threatening complications a {ter exposure to milk. Symptoms include feeding difficuties, hypoglycemia, renal tubular dysfunction, vomi ting, diarrhea, hepatomegaly, Escherichia coli sepsis, and cataracts. Long-term complications can include speech and cognitive disabilities, decreased bone mass and hyp ergonado trophic hypogonadism in the ma jority of females. In contrast to patients with classic galactosemia, patients with GALK deficiency do noth ave the same issue with consuming milk-based products. They do have high levels of galactose and galac titol in their blood and tissues and can develop cataracts, and rarely, central nervous system abnormalities. including mental retardation and pseudotumor cerebri, but these conditions can resoWve after eliminating g alactose from their diet early in life. Patients experience no long-term complications as long as the dietary restriction is followed. Epimerase deficiency resutts in a lack of phenotype in most patients, as the enzyme “] rT_| L deficiency is usually restricted to red and white blood cells, but thereis a very rare manifestation of the dis ease that has a symptom profil similar to that of classic galactoservia, Treatment: Treatment forall forms of galactosemia is immediate dietary restriction of galactose-containing foods. Inf ants can be given soy milk or formula containing other carbohydrate sources, or arrino acid-based eleme ntal formulas. When the patients reach childhood and beyond, galactose restriction is stil recommended but itis increasingly difficult to remove al galactose from the diet, as trace amounts are found in fruits, ve getables, bread, and lagumes. A study that compared treatment variation and outcomes in different count fies around the world found that in spite of widely disparate manners of monitoring patients, timing of tre atment initiation, and levels of dietary restriction, negative outcomes still occurred in the majority of case s. Ithas been hypothesized that increased concentrations of galactose-1-phosphateis the cause of thep athogenesis in classic galactosemia, and that small inhibitors of GALK could decrease the buildup of this metaboite, Ident.cation of inhibitors of GALK is in the early stages of scientific discovery, and use of thes emoleculesis far from being implernented clinically, 2. inborn Errors in Fructose Metabolism Fructose is found in high concentrations in fruits and in an increasing number of processed foods in the f ormof high fructose corn syrup (HFCS). There are three recognized inherited disorders of fructose metab olism, which vary quitea bit in severity. Essential fructosuria results froma deficiency of fructokinase an dleads to benign elevations of fructose in the blood and urine. As this disorder is asymptomatic and usu ally diagnosed incidentally, it will not be discussed further. Hereditary fructose intolerance (Fl) is an aut osomal recessive disorder caused by a mutation in the gene encoding the enzyme aldolase B. This gives rise to an accumulation of fructose-1-phosphate that inhibits glycogenolysis and gluconeogenesis. Fruct ‘05e1,6-bisphosphate (FBP) deficiency is also an autosomal recessive disorder due to mutation in the gen ethat encodes the FBP enzyme that causes impaired forrnation of glucose from all precursors, Clinical Presentation: Patients with HEI are usually healthy in the neonatal period and only manifest symptoms once they are w eaned and exposed to fructose, sucrose, or sorbitolin fruits and vegetables. Presenting symptoms include bloating, nausea and vomiting, hypoglycemia, restlessness, lethargy, and often with progression to coma IF ingestion of fructoseis continued, patients exhibit chronic conditions such as failure to thrive, ler disea se, and kidney dysfunction. In contrast to infants with HEI, infants with FBP can present as neonates with hypoglycemia and severe lactic acidosis due to reduced glycogen stores. As the patient ages and the toler ance to fasting improves, the symptoms decreasein both frequency and severity. These symptoms can in clude irritability, hepatomegaly, coma, and somnolence. in both conditions, exposure to intravenous soluti ons containing fructose can be fatal, so itis prudent to determine the sugar used in the solution prior toa dministration. Treatment: The treatment for HFl is the elimination of fructose from the diet. Once the patient no lon ger ingests fruct ose, sucrose, or sorbitol, clinical symptoms resolve and the prognosis is quite good. As the patient ages, to lerance for fructose inereases slightly. For patients with FBP, restriction of fructose is only recommended i “] rT_| n small children. The most critical feature to conitol is an avoidance of fasting, especially during a febrile ill ness, and the ability to fast improves with age. Treatment for an acute episede is oral or intravenous gluc ose and long-term treatment includes frequent feeding or use of uncooked comstatch or other slowly abs otbed carbohydrates 3. Glycogen Storage Diseases GSDs comprise a number of disorders that affect the metabolism of glyeogen. Glycogen serves as a reser voir of glucose, and mutations are found in the genes encoding the enzymes that regulate its processing, | eading to abnormal concentrations or structures, Glyeogenolysis, gluconeogenesis, and the production of lactate and ketone bodies can be affected, depending on the disorder. linical Presentation: GSD type 0s due to mutations in the glycogen synthase gene, GYS2, which lead to a decrease in liver gly cogen content. Patients have hypoglycemia and ketosis after short fasts and hyperlipidemia, as excess gl uucose cannot be converted to glycogen Patients with GSD type I (von Gierke disease) are unable to generate glucose through gluconeogenesis 0 r by the breakdown of glycogen dueto a mutation in the GPC gene, resulting in glucose 6-phosphat ase deficiency. Instead, patients form glucose6-phosphate, which when utiized in the cell, results in increased lactate, ipids, and uric acid. Patients pres ent in either the newborn period with hypoglycemic seizures or la ‘er ininfancy, as the time between feedings is increased, By 6 months of age, hepatomegaly and dolh-ike f acies are apparent, Platelet dysfunction and renal tubular acidosis can be added complications GSD type Il (Pompe disease) is caused by mutations in the glucose- 6-phos phate translocase gene, SLC 374, and also includes neutropenia and neutrophil dysfunction, leading to recurrent infections and poor ‘wound healing. GSD type Il (Pompe disease) is caused by mutation in the GAA gene and deficiency of lys ‘osomal acid-a-glucosidase enzyme (GAA). Pornpe disease is the only GSD that is also classified as a lys osomal storage disease. Patient's can present at a variety of different ages, with variable age of onset, sev erity, and progression of the disease. Despite these differences, all patients show an accumulation of glyc ogen in skeletal, cardiac, and smooth muscle, which leads to weakness, hypotonia, respiratory distress, an dpoor linear growth and weight gain. The infantile form tends to be rapidly progressing and lethal, with d eath dueto cardliorespiratory failure by the age of 1 year, while the late-onset form proceeds more slowly a rid lacks cardiac involvement, with the age of death dependent on therrate of disease progression. GSD type Ill (Cori disease) results froma mutation in the AGL gene. This causes a defect in the glycogen debranching enzyme, resulting in a phenotype that includes hypoglycemia with ketosis, hyperlipidemia, he patosplenomegaly, and myopathy. This disorder is further stratified by the involvement of skeletal muscle (GSD type Il) or nonskeletal muscle (GSD type Illb). As patients reach adolescence, their hypoglycemia be comes more stable, but myopathy, including cardiomyopathy and exercise intolerance, worsens. GSD type IV (Anderson disease) is caused by a mutation in the GBE1 gene encoding the glycogen branch ing enzyme and hasa variable presentation, depending on where the deficiency is located, Patients can h ave severe or mild liver forms, severe or mild neuromuscular forms, or a generalized severe form that is fat al. As expected with numerous forms, the presenting symptoms are quite variable and can include hepato splenomegaly and hepatic fibrosis, hypotonia, muscular atrophy, myopathy, cardiomyopathy, hydrops feta - “]_| L lis, exercise intolerance, and central and peripheral nervous system dysfunction. GSD type V (McArdle disease) is due to mut ation in the PYGM gene and deficiency of muscle phosphory lase activity, and muscles arenot ableto utilize muscle glycogen in the initial phase of physical activity. Af ter the blood supply increases and supplies the muscles with energy, patients are able to function normall y, in what is referred to asthe “second wind” phenomenon Symptoms don't present until the second or thir d decade of life and include exercise-induced muscle pain, fatigue, and, in some cases, rhabdomyolysis. GSD type VI (Hers disease) is caused by mutation in the PGYL gene and deficiency of the hepatic glycog ‘en phosphorylase and is the rarest of the GSDs, Unlike the other GSDs, it is not associated with hypoglyoe mia as the presenting symptom, but instead with hepatomegaly, mild lwer dysfunction, short stature, and hyperlipidemia, The clinical course for this disorder is quite benign, and most aduts are asymptomatic. GSD type Vil (Tarui disease) results from a mutation in the PFKM gene leading to deficiency of muscle fr uctokinase. tis clinically very similar to GSD type V, not only with exercise-induced pain, muscle cramps, a Ind fatigue, but also includes nausea and vorriting, hemolytic anemia, and hyperuricemia GSD type IX is subdivided into types Ika, IXb, and IXc, depending on which of the genes encoding the sub units of phosphorylase kinase contains the defect, PHKA2, PHKB, or PHKG2, respectively. Most patients havea mild course, with isolated hepatomegaly and fasting ketosis. Treatment: The main treatment for most GSDs is dietary, with the goal to maintain anormal blood glucose concentrat ion via ca rbohydrates in the diet. Uncooked comstarch is commonly used, with continuous feeding overni ght to prevent fasting and frequent feeding during the day. Continuous ghicose monitoring can be utilized to minirrize peaks and troughs in glucose levels Enzyme replacement therapy (ERT) with recombinant human GAA (thGAA) has emerged as a viable treat ment for patients with Pompe disease who also have cross-reactive immunologic material (CRIM-positiv ¢). An assessment of a cohort of 10 patients with infa ntile-onset Pompe disease who were identiled at bir th via newborn screening resutts and treated with rhG.AA for a median time period of 63 months showed t he benelts of ERT. The patients showed long-term survival when compared to untreated cases, and all the patients could walk independently and did not require mechanical ventilation. Muscle weakness did appea rafter 2 years of age, as well as ptosis and speech disorders.33 CRIM-negat ve patients, as well as CRIM: positive patients with highsustained antithGAA IgG antibody titers (HSAT) have been successfully treated with ERT in combination with immuno suppressive regimens including rituximab, methotrexate, intravenou s immunoglobulin, and bortezomib. Treatment of patients with adult-onset Pompe disease appears to be | ess effective in halting disease progression. A 5-year retrospective study found that pulmonary function w as stabilized but muscle endurance was not significantly enhanced as seen in previous studies. A separat e study that focused on quality of life in patients with adult-onset Pompe disease reported that ERT had a positive effect on patients’ physical health status and participation in daily life, as well as not only halting t he decline of their health status, but improving it in the first 2 years of treatment. “] rT_| L 4, Diabetes Diabetes mellitus is a group of metabolic disorders of carbohydrate metabolism characterized by high blood glucose levels (hyperglycemia) and usually resulting from insufficient producti on of the hormone insulin (type 1 diabetes) or an ineffective response of cells to insulin (typ 2 diabetes). Secreted by the pancreas, insulin is required to transport blood glucose (sugar) into cells. Diabetes is an important risk factor for cardiovascular disease, as well as a leading cause of adult blindness. Other long-term complications include kidney failure, nerve damage, and lower limb amputation due to impaired circulation, Type 1 diabetes (formerly known as juvenile-onset or insulin-dependent diabetes) can occu rat any age but often begins in late childhood with the pancreas failing to secrete adequate a mounts of insulin. Type1 diabetes has a strong genetic link, but most cases are the result of an autoimmune disorder, possibly set off by a viral infection, foreign protein, or environmental toxin. Although elevated blood sugar is an important feature of diabetes, sugar or carbohydrat ein the diet is not the cause of the disease. Type 1 diabetes is managed by injections of insult n, along with small, regularly spaced meals and snacks that spread glucose intake throughout the day and minimize fluctuations in blood glucose. Type 2 diabetes (formerly known as adult-onset or non-insulin-dependent diabetes) is the more common type of diabetes, constituting 90 to 95 percent of cases. With this condition, in sulin resistance renders cells unable to admit glucose, which then accumulates in the blood. A Ithough type 2 diabetes generally starts in middle age, it is increasingly reported in childhood, especially in obese children. Genetic susceptibility to this form of diabetes may not be expres sed unless a person has excess body fat, especially abdominal obesity. Weight loss often hel ps to normalize blood glucose regulation, and oral antidiabetic agents may also be used. Life style intervention (e.g., diet and exercise) is highly ef fective in delaying or preventing type 2 di abetes in high-risk individuals. Compiled by: Mr. Edom, C.V. “d 2s i