Gout and Purine degradation

Arun.S
MIT University, Biochemistry Project report

Abstract
Purine degradation is an absolutely essential process in our body, the final product of
which is uric acid. This uric acid is then excreted through our system. Gout is a disorder
that is caused when something goes wrong with this system and excess uric acid is
created, leading to hyperuricemia. This report will go into detail as to how this takes
place and what can be done to solve this problem.

Introduction
A purine is a heterocyclic aromatic organic compound that consists of a pyrimidine ring
fused to an imidazole ring. Purines are an essential group of nitrogenous bases that can
be broken down into uric acid for further excretion. Hyperuricemia refers to an elevation
in the serum uric acid concentration, and is what happens in the case of gout. Gout is a
metabolic disease associated with overproduction of uric acid. At the physiological pH,
uric acid is found in a more soluble form as sodium urate. In severe hyperuricemia,
crystals of sodium urate get deposited in the soft tissues, particularly in the joints. This
leads to excruciating amounts of pain to the victims due to the inflammation caused by
the crystals.

Uric Acid Sodium Urate

Purine degradation

The nucleotide monophosphates (AMP, IMP & GMP) are converted to their respective
nucleoside forms (adenosine, inosine & guanosine) by the action of nucleotidase. The,
the amino group, either from AMP or adenosine, can be removed to produce IMP or
ionosine. Inosine & guanosine are converted to hypoxanthine & guanine (purine bases)
by purine nucleoside phosphorylase. Adenosine is not degraded by this enzyme, it has
to be converted to inosine. Guanine undergoes deamination by guanase to form
xanthine. Xanthine oxidase converts hypoxanthine to xanthine & xanthine to uric acid.
This enzyme contains FAD, molybdenum & iron. It is exclusively found in liver & small
intestine. Xanthine oxidase liberates H2O2 which is harmful to the tissues. Catalase
cleaves H2O2 to H2O & O2.

Degradation of uric acid in other animals

Most other animals (excluding primates) are unable to directly excrete uric acid. Instead
other reactions take place in order to convert uric acid into a form that can be excreted.
A lot of animals oxidize uric acid by the enzyme uricase into allantoin, where the purine
ring is cleaved. Allantoin is then converted into allantoic acid & excreted in some fishes.
Further degradation of allantoic acid may occur to produce urea (in amphibians, most
fishes & some molluscs) & to ammonia (in marine invertebrates).

Primary gout
Primary gout is related to under excretion or overproduction of uric acid, often
associated with a mix of dietary excesses or alcohol overuse and metabolic syndrome.
This is mostly related to increased synthesis of purine nucleotides. About 10% of cases
of primary gout are idiopathic (spontaneous with unknown cause). Incidence of primary
gout is about 3 per 1,000. Furthermore it seems to disproportionately target males.
Causes of primary gout
Loss of feedback control over PRPP Synthetase: Inosine monophosphate is
synthesized by a series of reactions that being with Ribose-5-Phosphate. This is
obtained from the oxidative phase of the Pentose-Phosphate pathway.

This is a diagram of the initial step. As we can see, R5P is activated with ATP to form
PRPP (5-Phosphoribosyl-a-pyrophosphate). This reaction is catalyzed by the enzyme
Ribose phosphate pyrophosphokinase (PRPP Synthetase). In normal circumstances,
PRPP Synthetase is under feedback control by purine nucleotides (ADP & GDP).
However, variant forms of this enzyme such as PRPP glutamylamidotransferase are not
regulated by any feedback mechanism. A lack of regulation over this reaction leads to
the excess production of IMP which in turn leads to excess uric acid formation. This is
the de-novo synthesis of purines as it is being created from scratch.

Deficiency of HGPRT enzyme: Purines can also be generated in our body through the
degradation of nucleic acids in the salvage pathway. Turnover of nucleic acids in most
cells leads to the formation of adenine, guanine and hypoxanthine. Purines are
salvaged by 2 different enzymes in mammals.
1) Adenine + PRPP AMP + PPi
This reaction is catalyzed by the enzyme Adenine phosphoribosyltransferase (APRT).
2) Hypoxanthine + PRPP IMP + PPi
Guanine + PRPP GMP + PPi
These reactions are catalyzed by the enzyme Hypoxanthine-guanine
phosphoribosyltransferase (HGPRT).

LeschNyhan syndrome (LNS), also known as Nyhan syndrome and juvenile gout, is
a rare inherited disorder caused by a deficiency of the enzyme hypoxanthine-guanine
phosphoribosyltransferase (HGPRT), produced by mutations in the HPRT gene located
on the X chromosome. This deficiency is bad for 2 reasons. Firstly, decreased utilization
of purines (hypoxanthine & guanine) by salvage pathway. Resulting in accumulation &
diversion of PRPP for purine nucleotides. Secondly, the defect in salvage pathway
leads to decreased levels of IMP & GMP causing impairment in the tightly controlled
feedback regulation of their production.

This syndrome is an X-linked recessive disorder and hence can only affect males. The
periods before and surrounding birth are typically normal in individuals with LNS. The
most common presenting features are abnormally decreased muscle tone (hypotonia)
and developmental delay, which are evident by three to six months of age. Affected
individuals are late in sitting up, while most never crawl or walk. Lack of speech is also a
very common trait associated with LNS.

Irritability is most often noticed along with the first signs of nervous system impairment.
Within the first few years of life, extrapyramidal involvement causes abnormal
involuntary muscle contractions such as loss of motor control (dystonia), writhing
motions, and arching of the spine. Signs of pyramidal system involvement, including
spasticity, overactive reflexes and extensor plantar reflexes, also occur. The motor
disability is so extensive that most individuals never walk, and become lifelong
wheelchair users.

Persons affected are cognitively impaired and have behavioral disturbances that
emerge between two and three years of age. The uncontrollable self-injury associated
with LNS also usually begins at three years of age. The self-injury begins with biting of
the lips and tongue; as the disease progresses, affected individuals frequently develop
finger biting and head banging. The self-injury can increase during times of stress. Self-
harm is a distinguishing characteristic of the disease and is apparent in 85% of affected
males.

Glucose-6-phosphatase deficiency: This condition is known as Von Gierke's

disease (glycogen storage disease, type I). When this enzyme is deficient, glucose-6
phosphate cannot be converted to glucose. More glucose is channeled into the HMP
shunt, resulting in increased availability of ribose-5-phosphate. This leads to increased
formation of PRPP & purine over production as PRPP is essential for the synthesis of
IMP.
Symptoms of this disease include constant hunger and need to eat often, easy
bruising and nosebleeds, fatigue, irritability, puffy cheeks, thin chest and limbs, and
swollen belly.

Secondary Gout
It is due to various diseases causing increased synthesis or decreased excretion of
uric acid. Increased degradation of nucleic acids is observed in various cancers
(leukemias, polycythemia, lymphomas, etc.) psoriasis & increased tissue breakdown
(trauma, starvation etc.) & impairment in renal function cause accumulation of uric
acid, lead to gout.

Treatment of gout
The drug, allopurinol is used for primary gout. It is a structural analog of
hypoxanthine that competitively inhibits enzyme xanthine oxidase. Allopurinol is
oxidized to alloxanthine by xanthine oxidase. Alloxanthine, is a more effective
inhibitor of xanthine oxidase & is referred to as suicide inhibition. Inhibition of
xanthine oxidase by allopurinol leads to the accumulation of hypoxanthine &
xanthine, which are water soluble & easily excreted.
Furthermore, restriction in dietary intake of purines & alcohol is advised.
Consumption of plenty of water is useful. The anti-inflammatory drug colchicine is
used for the treatment of gouty arthritis.

Conclusion
As we can see from this report, Purine degradation and Gout are intrinsically linked.
Various defects in purine degradation, result in an excess production of Uric acid
which in turn causes a variety of defects. Even if there is nothing wrong with the
purine degradation pathway, Excess uric acid can still be produced by the excess
formation of purines. We have also looked at the LeschNyhan syndrome (LNS)
which affects infants and Von Gierke's disease. By understanding these
mechanisms we get a better idea of how to cure such disorders. Luckily in the
modern world, these afflictions are easily treatable thanks to the advancements in
understanding these pathways and mechanisms.