You are on page 1of 4

Jessica Caricato Nutrition 445 Case Study 2 Due October 16, 2013 Pyruvate carboxylase deficiency & dysfunction

of the Krebs cycle: A 3-month old female infant seemed normal until she developed seizures. The infant became progressively worse, showing hypotonia, psychomotor retardation, and poor head control. She had lactic acidosis and an elevated plasma pyruvate level, both more than seven times the normal amount. Plasma alanine concentration was high, and an alanine load failed to induce a normal gluconeogenic response. Pyruvate carboxylase activity was measured using extracts of cultured skin fibroblasts and was found to be less than 1% of the normal level. Both the mother and the father had intermediate levels of fibroblastic pyruvate carboxylase. Fibroblasts from the patient accumulated five times greater than normal amounts of lipid. Questions: 1. What reaction is catalyzed by pyruvate carboxylase? And where is the enzyme located within cells? Pyruvate carboxylase catalyzes the reaction in which pyruvate is carboxylated (CO2 added) to form oxaloacetate. This reaction is irreversible.

Pyruvate carboxylase is located in the mitochondria, and contains a biotin moiety which transfers the carboxyl group intermediate in the above reaction to the pyruvate to form oxaloacetate (Jitrapakdee, 2008). This reaction is dependent on HCO3-, ATP, and Mg. Pyruvate carboxylase is stimulated by high levels of acetyl-CoA, and inhibited by high levels of ADP. Pyruvate carboxylase replenishes oxaloacetate taken from the Krebs Cycle, and also serves a regulatory role in controlling fuel appropriation (ATP) towards various biochemical pathways: gluconeogenesis, lipogenesis, and insulin secretion (Jitrapakdee, 2008).

A deficiency in pyruvate carboxylase causes a buildup of lactic acid in the blood, as the accumulation of pyruvate not being converted to oxaloacetate will instead be converted to lactate by lactate dehydrogenase (Wang, 2009).

2. What is the metabolic function of pyruvate carboxylase? The metabolic function of pyruvate carboxylase is to make oxaloacetate for both gluconeogenesis (where pyruvate carboxylase is the first rate-limiting step) and intermediates of the Krebs Cycle. It is needed metabolically to form glucose through gluconeogenesis when blood glucose levels are not high enough. After oxaloacetate is created by pyruvate carboxylase, it then becomes phosphoenolpyruvate (PEP), a reaction catalyzed by PEP carboxylase (Attwood, 1995). Following the step where PEP is formed, the pathway of gluconeogenesis follows the same steps of glycolysis in reverse, until glucose is formed.

3. Explain the failure of the alanine load to induce gluconeogenesis in the patient? Alanine can be converted to pyruvate, which will go on to enter gluconeogenesis and form glucose, if all necessary enzymes are present. An alanine load can be given to form pyruvate through transamination if the reason for the lack of gluconeogenesis is a deficiency in pyruvate. However, this patient is not deficient in pyruvate, but rather has elevated plasma levels, so simply creating more pyruvate will not fix the problem. This patient is deficient in the enzyme pyruvate carboxylase, and it therefore does not matter how much pyruvate there is. The patient is unable to catalyze the conversion from pyruvate to oxaloacetate, and if this step does not occur, the pathway of gluconeogenesis shuts down. Gluconeogenesis cannot happen without pyruvate carboxylase, no matter how much pyruvate is formed.

4. Glutamine greatly simulated the growth of fibroblasts from a patient with pyruvate carboxylase deficiency. Why? Glutamine is utilized by fibroblasts as an energy source. The oxidation of glutamine supplies a large amount of the energy required by fibroblasts for growth, and the rate of glutamine oxidation to create energy for use by fibroblasts is regulated by glucose. In low-glucose environments, as is the case with this patient, there is no regulation of glutamine oxidation. The oxidation of glutamine increases exponentially if not regulated by glucose (Zielke, 1978), and the increase in energy that results from more glutamine oxidation would subsequently stimulate the growth of more fibroblasts. A patient with a pyruvate carboxylase deficiency would see growth of fibroblasts due to this reason because the patients inability to preform gluconeogenesis could lead to there being less glucose to regulate glutamine oxidation.

5. What treatment would you suggest for a patient with this disease? There are two main phenotypes of pyruvate carboxylase deficiency, in order to treat the problem, it would help to diagnose which of the two the patient has. The first type, called Type A or the North American type, usually causes illness at 2-5 months of age. The symptoms are noticed at birth and get progressively worse. These symptoms include: hypotonia, inability to hold up head, obvious signs of mental retardation, and unawareness of surroundings. The second phenotype, Type B or the French type, typically manifests and causes death in the neonatal period (the first 28 days of life) (Merleir, 2013). Based on this data, I would diagnose this patient with Type A pyruvate carboxylase deficiency. There are no long-term treatments of pyruvate carboxylase (PC) deficiency, and death in infancy or early childhood is common. In some cases, there are ways to manage the disease, although neurological manifestations of the disease are not fixed through these interventions, so the patient will still show signs of mental retardation even if the acute management methods work (Wang, 2009). The methods I would suggest are: 1. Intravenous glucose-containing doses: Since gluconeogenesis is not occurring in the patient, he or she is deriving energy from glucose solely through glycolysis. It is imperative to make sure the patient always has a high enough glucose intake so that the lack of gluconeogenesis is less of a problem for the tissues which use only glucose as fuel (Mochel, 2005). 2. A high carbohydrate and high-protein diet, along with lack of fasting. If glucose levels from dieting are sufficient, the bodys inability to enter gluconeogenesis will not be a problem because the body will be in an anabolic state and will not need to activate gluconeogenesis. 3. Citrate supplementation: If citrate is added to the diet, it will help alleviate acidosis and also provides a substrate for use in the citric acid cycle so that the cycle can still function even with the bodys inability to produce oxaloacetate from pyruvate (Wang, 2009). 4. Aspartic acid supplementation: Aspartic acid will be low in a patient with PC deficiency because it is derived from oxaloacetate, which someone with a PC deficiency could not make. Supplementing aspartic acid will allow the urea cycle to continue so that the body has a way of disposing of ammonia (Garcia-Cazorla, 2006).

References: Attwood PV: The structure and the mechanism of action of pyruvate carboxylase. Int J Biochem Cell Biol. 27(3):231-49, 1995. Garca-Cazorla A, Rabier D, Touati G, Chadefaux-Vekemans B, Marsac C, de Lonlay P, Saudubray JM: Pyruvate carboxylase deficiency: metabolic characteristics and new neurological aspects. Ann Neurol. 59(1):121-7, 2006. Jitrapakdee S, St Maurice M, Rayment I, Cleland WW, Wallace JC, Attwood PV: Structure, mechanism and regulation of pyruvate carboxylase. Biochem. J. 413 (3): 36987. Merleir LD: Disorders of pyruvate metabolism. Handb Clin Neurol. 113:1667-73, 2013. Mochel F, DeLonlay P, Touati G, et al: Pyruvate carboxylase deficiency: clinical and biochemical response to anaplerotic diet therapy. Mol Genet Metab. 84(4):305-12, 2005. Wang D, De Vivo D: Pyruvate carboxylase deficiency. GeneReviews (Internet). 2009: Online ahead of print. Zielke HR, Ozand PT, Tildon JT, Sevdalian DA, Cornblath M: Reciprocal regulation of glucose and glutamine utilization by cultured human diploid fibroblasts. J Cell Physiol. 95(1):41-8, 1978.
1

You might also like