Presentation on Inborn errors of metabolism

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Presentation on Inborn errors of metabolism

  1. 1. BY:-RICHA PRITWANIMsc. Foods And Nutrition (Specialization in foodscience and Processing)
  2. 2. PhenylketonuriaPKU (phenylketonuria), is a rare, inheritedmetabolic disease that results in mentalretardation and other neurological problemswhen treatment is not started within the firstfew weeks of life.Genotype:•In cases of PKU, the enzyme that breaks downphenylalanine, phenylalanine hydroxylase, iscompletely or nearly completely deficient.Mutation of the enzyme, phenylalaninehydroxylase (PAH).Phenotype:•Mental Retardation, Seizures, Fair Skin, “MousyOdor” & Eczema.
  3. 3. PAH Mutation-• Most common is located at position 408• A substitution of an Arginine with a Tryptophan(Arg408Trp).Aberrant Function-• Reduces the activity of PAH• Phenylalanine ingested in foods cannot be metabolized and accumulates to toxic levels in the bloodstream and other body tissuesDiagnosis PAH deficiency can be diagnosed by newborn screeningA normal blood phenylalanine level is about 1mg/dl and in PKU:Blood phenylalanine >6 -10 mg/dl or (360-600 µmol/L)Blood tyrosine < 3mg/dl (165 µmol/L)
  4. 4. The normal metabolism of phenylalanine (pathways a and b) BREAKDOWNDietarysources, PHENYLALANINEparticularly HYDROXYLASE PHENYLALANINE TYROSINEplant (a)proteins (b) BODY PROTEINS
  5. 5. The abnormal metabolism in phenylketonuric subjects (pathway c) HYDROXYPHENYLACETIC ACID (c)Dietarysources, PHENYLALANINEparticularly HYDROXYLASE PHENYLALANINE*plant (a)proteins (c) (b) PHENYLACETIC BODY ACID* PROTEINS *Agents, thought to be responsible for mental retardation
  6. 6. WHO DOES PKU EFFECT? PKU is an autosomal recessive disorder. When both parents are carriers, there is: ◦ A 1-in-4 (25 percent) chance that both will pass one abnormal PAH gene on to a child, causing the child to be born with PKU. ◦ A 2-in-4 (50-50) chance that the baby will inherit one abnormal PAH gene from one parent and the normal gene from the other, making it a carrier like its parents. The “carrier” for PKU does not have the symptoms. ◦ A 1-in-4 (25 percent) chance that both parents will pass on the normal gene. The baby will neither have the disease nor be a carrier.
  7. 7. SYMPTOMS OF PKU(About 50% of untreated infants have the following earlysymptoms)  Infants with classic PKU appear normal until they are a few months old.   Without treatment with a special low-phenylalanine diet, these children develop permanent intellectual disability.   Seizures, delayed development, behavioral problems, and psychiatric disorders  Untreated individuals may have a musty or mouse-like odor as a side effect of excess phenylalanine in the body.   Children with classic PKU tend to have lighter skin and hair and are also likely to have skin disorders such as eczema.  Vomiting and Irritability  Unusual odor to urine  Nervous System Problems(increased muscle tone, more active muscle tendon reflexes)  Microcephaly  Decreased body growth and prominent cheek and jaw bones widely spaced teeth and poor development of tooth enamel
  8. 8. Medical Management•Regular monitoring of blood phenylalanine•To maintain at 1-6 mg/dl (60-350 µmol/L)Nutrition assessment•Assess parental and family support for important nutrition therapyNutrition care•Phenylalanine – free formula/medical food•Low phenylalanine foods•Supplement with tyrosine•Education of family and child about formula/medical food preparation•Adequate nutritional intake•Regular monitoring of growth•Education on label reading and food choicesHowever, the current recommendation of most clinics is effectivemanagement of blood Phe concentration throughout a lifetime.
  9. 9. Medical Nutrition TherapyFor PKU dietary therapy is planned around the use of aformula/medical food and protein source with L-amino acid, Pheremoved from the protein.Carbohydrate sources are corn syrup solids, modified tapiocastarch, sucrose, and hydrolyzed cornstarch. Fat is provided by avariety of oils. Some formulas and medical foods contain no fat orcarbohydrate; therefore these components must be provided fromother sources.Phe-free formula is supplemented with regular infant formula orbreast milk during infancy and cows milk in early childhood toprovide high-bv protein, nonessential amino acids, and sufficient Pheto meet the individualized requirements of the growing child.The optimal amount of protein substitute depends on theindividuals age (and thus requirements for growth) and enzymeactivity and must be individually prescribed.
  10. 10. The Phe-free formula and milk mixture should provide about90% of the protein and 80% of the energy needed by infants andtoddlers.Certain vegetables, fruits, and some grains can then be addedin to the diet after infancy.Regular meats, eggs, fish, milk, and cheese are never to beadded into the diet.Diet drinks and foods that contain the artificial sweeteneraspartame (which contains Phe) must always be avoided. Ex:Nutrasweet or EqualPhe-free formula needs to be followed throughout childhoodand adolescence because protein is needed for development.
  11. 11. Tyrosinemia Inborn error in the degradation of the tyrosine. People have problems breaking down an amino acid tyrosine from the food they eat. Hereditary – autosomally recessive. Three types Type I – deficiency of the enzyme fumarylacetoacetate hydrolase (FAH). Type II – deficiency of the enzyme tyrosine aminotransferase (TAT). Type III – deficiency of the enzyme 4- hydroxyphenylpyruvate dioxygenase (HPPD).
  12. 12. Parents of children with tyrosinemia 1 rarely have the condition themselves. Instead,each parent has a single non-working gene for the condition. They are calledcarriers.Carriers do not have the condition because the other gene of this pair is workingcorrectly.   
  13. 13. Type I Tyrosinemia Tyrosinemia 1 occurs when an enzyme, called fumarylacetoacetase (FAH), is either missing or not working properly. There is a mutation in the FAH gene that encodes for the FAH enzyme. When FAH is not working, it cannot break down tyrosine. Tyrosine and other harmful substances then build up in the blood. Can be either chronic or acute. ◦ Acute – infancy ◦ Chronic – later in life
  14. 14. Symptoms of Type I Tyrosinemia Failure to gain weight or grow Diarrhea, bloody stools and vomiting Jaundice of skin and eyes Cabbage-like odor to the skin or urine Increased tendency to bleed (esp. nosebleeds) extreme sleepiness irritability enlarged liver yellowing of the skin tendency to bleed and bruise easily swelling of the legs and abdomen Liver cirrhosis and/or hepatocellular carcinoma (chronic) Kidney problems rickets delays in walking
  15. 15. Fumarylacetoacetate Hydrolase FAH is the last in the series of five enzymes needed to catabolize tyrosine. Metalloenzyme Catalyzes the hydrolysis of 4-fumarylacetoacetate to fumarate + acetoacetate. Deficiency of FAH results in accumulation of succinylacetone, maleylacetoacetone, and fumarylacetoacetate. When succinylacetone builds up in the blood, it causes serious liver and kidney damage. It may also cause episodes of weakness or pain.  
  16. 16. Type II Tyrosinemia Caused by a mutation in the TAT gene that encodes for the hepatic (liver) TAT enzyme. Also known as “Richner-Hanhart syndrome” TAT gene – Codes for tyr aminotransferase Which is responsible for converting tyrosine to 4- hydroxyphenylpyruvate. TAT is the enzyme involved in the first of a series of five reactions of tyrosine degradation. Occurs in cytosol Pyridoxal 5’-phosphate (PLP) dependent enzyme Transaminates tyrosine and α-ketogluterate into p- hydrophenylpyruvate and glutamate.
  17. 17. Symptoms of Type II Tyrosinemia Elevated serum and plasma tyrosine levels Lesions of skin and eyes ◦ Due to clumping of cellular tyrosine crystals. Excessive tearing, abnormal sensitivity to light (photophobia), lacrimation, burning eye pain, inflamed conjunctiva Microcephaly - Mental retardation (caused by elevated blood tyrosine levels) Blistering lesions on the palms and soles delay behavioral problems and self injurious behaviors also occurring frequently Symptoms often begin in early childhood
  18. 18. Type III Tyrosinemia Deficiency of 4-hydroxyphenylpyruvate dioxygenase (HPPD) Caused by a mutation in the HPPD gene that encodes for the enzyme HPPD Second enzyme involved in tyrosine catabolism pathway Requires Fe(II), oxygen and a alpha-keto acid substrate (typically alpha- ketoglutarate)
  19. 19. Symptoms of Type IIITyrosinemia Mild mental retardation Seizures Loss of balance and coordination (intermittent ataxia) High blood and urine concentrations of tyrosine and HPP
  20. 20. Diagnosis Newborn screen Tandem mass spectrometry Maintaining tyrosine levels below 800µmol/l appears to be protective against pathology including neurological squeal
  21. 21. Goals of dietary management:1. Support an appropriate rate of growth2. Support normal intellectual development3. Maintain optimal nutritional status4. Provide adequate nourishment5. Prevent neurological crisis6. Prevent liver and renal function problems7. Prevent formation of tyrosine crystals in the eyes (this occurs with elevated plasma tyrosine levels)
  22. 22. The following treatments are often recommendedfor children with tyrosinemia 1:2. A medication called nitisinone (Orfadin® ), also known as NTBC (2-(2-nitro-4-trifluoro-methylbenzoyl)-1,3- cyclohexanedione) is used to block metabolism and to prevent liver and kidney damage. It also stops the neurologic crises. The medication may also lessen the risk for liver cancer.3. Vitamin D supplements are sometimes used to treat children who have rickets. 4. The special medical formula gives babies and children the nutrients and protein they need while helping keep their tyrosine levels within a safe range.5. Liver transplant (popular in 1980s)
  23. 23. Nutritional treatment The diet is made up of foods that are very low in tyrosine and phenylalanine (aim is below 500 μmol/L) and it is made up of special medical formula. There are other medical foods such as special flours, pastas, and rice that are made especially for people with tyrosinemia 1. There is a need to limit foods such as: cow’s milk meat eggs and cheese regular flour dried beans Nuts and peanut butter
  24. 24. Wilson’s diseaseDescribed as a clinical entity by Kinnear – Wilson in1912, this disorder was related to copperaccumulation in liver and brain in the 1940an autosomal recessive diseaseAbout 95% of serum copper is bound toceruloplasmin. serum ceruloplasmin level is usually low in thisdisease. The copper in liver cells is not excreted and isthought to cause oxyradical damage“hepatolenticular degeneration”leads to organ damage, specifically of the liver andbrain, due to buildup of copper
  25. 25. Pathogenesis Out of the 23 different human chromosomes, the generesponsible for Wilson disease is located on chromosomearm 13q, which has been shown to affect the copper-transporting adenosine triphosphatase (ATPase) gene(ATP7B) and it contains the genetic information necessary tomake a copper transport protein that plays a key role inincorporating copper into ceruloplasmin and moving excesscopper out of the liver.
  26. 26.  The two fundamental disturbances of copper metabolism in Wilson’s disease are (1) a gross reduction in the rate of incorporation of copper into ceruloplasmin, and (2) a considerable reduction in billiary excretion of copper. Ceruloplasmin is a copper protein which is a glycoprotein and it has just one polypeptide. ATP7B gene provides instructions for making a protein called copper-transporting ATPase 2. Copper-transporting ATPase 2 is found primarily in the liver, with smaller amounts in the kidneys and brain. It plays a role in the transport of copper from the liver to other parts of the body. Copper-transporting ATPase 2 is also important for the removal of excess copper from the body.
  27. 27. Clinical FeaturesThe condition is characterized by excessive deposition ofcopper in the liver, brain, and other tissuesHepatic·         Asymptomatic hepatomegaly·         Isolated splenomegaly·         Persistently elevated serum aminotransferase activity·         Fatty liver·         Acute hepatitis·         Resembling autoimmune hepatitis·         Cirrhosis: compensated or decompensated·         Acute liver failure 
  28. 28. Neurological·         Movement disorders (tremor, involuntary movements)·         Migraine headaches·         Insomnia·         SeizuresPsychiatric·         Depression·         Neurotic behaviours·         Personality changes·         Psychosis Other Systems·         Ocular: Kayser-Fleischer rings, sunflower cataracts·         Renal abnormalities: aminoaciduria and nephrolithiasis·         Skeletal abnormalities: premature osteoporosis and arthritis·         Cardiomyopathy, dysrhythmias·         Pancreatitis·         Hypoparathyroidism·         Menstrual irregularities; infertility, repeated miscarriages
  29. 29. Diagnosis of Wilson disease Low serum ceruloplasmin <20mg/dl Symptomatic patient with high urine copper level>100ug/day 24hr urine copper excretion – high in Wilson’s disease Kayser-Fleischer rings Concentration of copper in liver biopsy sample >250ug/g dry weight Genetic testing: ◦ Defect on chromosome 13, in ATP7B gene  Various mutations, with varied phenotypic effects ◦ Carrier testing now available
  30. 30. Kayser-Fleischer rings A ring of golden-brown or brownish-greenpigment behind the limbic border of thecornea (Descemet’s membrane), due to thedeposition of copper.
  31. 31. Diet in wilson’s disease low-copper diet - avoiding mushrooms, dried fruit, chocolates, liver, shellfish, organ meats, dark GLV, raisins, radishes, nuts (especially almonds) oranges, blacks trap molasses, avocados, and broccoli. many of the foods and protein sources in a vegetarian diet are high in copper Supplements of vitamin B6
  32. 32. Familial hypercholesterolemiaFamilial Hypercholesterolemia (FH) is a disorder that resultsin elevated plasma cholesterol levels specifically very high levelsof low-density lipoprotein (LDL) in the blood. Disorder of absent or grossly malfunctioning LDL receptorswhich is responsible for binding to apolipoprotein B. LDL inblood and internalizing these particles. An inability tointernalize LDL results in increased cholesterol synthesis by theliver.A single abnormal copy (heterozygote) of FH causescardiovascular disease by the age of 50 in about 40% of caseswith a frequency of 1 in 500 (heterozygous FH ) and results indecreased levels or activity of the LDL receptor.Having two abnormal copies (homozygote) causes acceleratedatherosclerosis in childhood, including its complications and itis more rare, occurring with the frequency of about 1 in a
  33. 33. Contd..Dominantly inherited disorder- deficiency in a cell surface LDL-R (the receptor regulates LDL degradation and cholesterol synthesis) - high cholesterol (since birth) - high LDL-C leads to premature atherosclerosis, xanthomas of skin and tendons TC>240 mg/dl LDL>190 mg/dl
  34. 34. Contd…•The combination of decreased clearance of LDL cholesterol andincreased cholesterol synthesis forces plasma cholesterol levels toincrease to 250-500 mg/dl in heterozygous FH and 600-1000 mg/dl inhomozygous FH individuals. Defects in the LDL receptor Defect Phenotype Synthesis Most common defect, Receptor not synthesized in the ER Receptor not transported from the  ER to the Golgi Transport apparatus for expression on the cell surface Receptor on cell surface, can’t bind to apo B on LDL because of LDL Binding a defect in either apolipoprotein B100 (R3500Q) or in LDL-R Receptor binds to apo B on LDL, can’t internalize LDL. It does Internalization not properly cluster in clathrin-coated pits for receptor-mediated endocytosis. Recycling Receptor internalizes LDL, but isn’t recycled to cell surface
  35. 35. Five classes LDL-R bind LDL particles of LDL-R mutations and endocytoses them 1 Null (no protein via clathrin-coated vesicles synthesis) 2 Transport defect (Golgi) 3 LDL binding defect 4 Internalization- defective 5 Recycling-defectiveFH Sites for LDL-R defects LDL-R is recycled 1 2 Receptors accumulate in coated pin region 4 5 Exocytosis of receptor Binding 3 to receptor Receptor Receptor synthesis processing Endocytosis of LDL in ER in Goldgi
  36. 36. Physical signsCholesterol may be deposited in various places in the body that arevisible from the outside, such as inyellowish patches around the eyelids (xanthelasma palpebrarum)the outer margin of the iris (arcus senilis corneae)in the form of lumps in the tendons of the hands, elbows, knees andfeet, particularly the Achilles tendon (tendon xanthoma)Cardiovascular diseaseatherosclerosis, the underlying cause of cardiovascular diseaseangina pectoris or heart attacks.transient ischemic attacks or occasionally strokePeripheral artery occlusive disease (obstruction of the arteries ofthe legs) occurs mainly in people with FH who smoke;this can cause pain in the calf muscles during walking that resolveswith rest (intermittent claudication) andproblems due to a decreased blood supply to the feet (suchas gangrene)
  37. 37. TreatmentThe goal of treatment is to reduce the risk of atheroscleroticheart disease. Those who inherit only one copy of the defectivegene may respond well to diet changes combined with statindrugs.LIFESTYLE CHANGESDiet changes include reducing total fat intake to less than 30%of the total calories.•Reduction of saturated fat intake by:Decreasing amounts of hydrogenated fatsSubstituting low-fat dairy products for full-fat ones•Reduction of cholesterol intake by eliminating egg yolks andorgan meats•Dietary counseling is often recommended to help peoplemake these adjustments to their eating habits. Weight loss andregular exercise may also aid in lowering cholesterol levels.
  38. 38. MEDICATIONSThere are several types of drugs available to help lower bloodcholesterol levels. Some are better at lowering LDL cholesterol,some are good at lowering triglycerides, while others help raise HDLcholesterol.The most commonly used and effective drugs for treating high LDLcholesterol are called statins.Other cholesterol-lowering medicines include:Bile acid-sequestering resinsEzetimibeFibrates (such as gemfibrozil)Nicotinic acidThose with more severe forms of this disorder may need atreatment called extracorporeal apheresis. This is the most effectivetreatment. Blood or plasma is removed from the body. Special filtersthen remove the extra LDL-cholesterol, and the blood plasma is thenreturned.

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