Biochemistry

Carbohydrates metabolism
Lec.10

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Insulin and C-Peptide:

We have a problem, the problem is when a diabetic patient comes, and he

would like to measure his insulin level. sometimes, you do not wait to
measure his insulin, you decide to give treatment straight away. And
sometimes, some diabetic patient after a while, they start producing
insulin as well. So, while you are giving him treatment (exogenous
injection of insulin) and they are producing insulin, later on when you
start measuring the insulin, you do not know whether this insulin is
exogenous or endogenous (especially when people change their insulin's
dose or their insulin's manufacture). So how do we solve this problem ?

Remember that Insulin consists of two polypeptide (α-ploypeptide and β-

polypeptide) linked by two disulphide bonds. Insulin is a very small
protein of 51 amino acids of two polypeptides. Prior to release, insulin is
stored in granules within the cell not in the form of insulin but in the form
of which is known as proinsulin.

- Proinsulin differs from insulin in an additional peptide (known as

c-peptide) which connects the a-polypeptide with b-polypeptide.
Prior to release, this polypeptide splits and is released with insulin
in the blood. So, when you measure c-polypeptide , it is equimolar
to the amount of insulin which is synthesized. So now it does not
matter if you give insulin because there is no c-polypeptide with
this insulin. So now when we measure c-polypeptide , it is an
indication of endogenously synthesized insulin by the B-cells in
pancreas.

(so, c-polypeptide is used to determine how much endogenous insulin has

been synthesized).

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The Polyol Pathway:

Glucose in a normal level (5 mmol in the cell) is metabolized by enzymes

which have a low Km value it glucose (high affinity to glucose).
Enzymes that have a high Km value cannot function (they need a very
long time to function). There is an enzyme known as aldose reductase
which has a high Km value to glucose. So, this enzyme under normal
condition will not work on glucose. But remember that if we increase the
concentration of the substrate very much, then enzymes with high Km
values will function also. In diabetes , there is a high level of glucose .
intracellularly, there is a high concentration of glucose level in the cells
which are insensitive physiologically to insulin (e.g. RBCs). So, in this
case, Glucose can be reduced by the action of aldose reductase to sorbitol
(sugar alcohol). Sorbitol ,consequently, acted upon by sorbitol
dehydrogenase to fructose (so now glucose is metabolized). In
hyperglycemia , glucose level is high in tissue such as RBCs, nerves and
lenses. Consequently, a huge amount of glucose is converted to fructose
by sorbitol dehydrogenase. Sorbitol dehydrogenase oxidizes sorbitol
which means producing electrons and give it to NADPH. So if this go on,
most or all NADP will convert to NADPH which result in depletion of
NADPH. NADPH is the major reducing agent intracellularly . we use
NADH to get energy while NADPH as a reducing agent.

In the eye's lens , where there is a high level of oxidation going on due to
the light goes through the lens , many of the proteins become oxidized
and we need to reduce them by NADPH. But there is no NADPH , so this
is the start of formation of cataract in the eye. So the cataract in diabetic
patients is caused by depletion of NADPH due to increased activity of
aldose reductase due to high concentration of glucose.

If this happens in nerve endings, it will lead to polyneuritis then damage

of nerves and that why most diabetic patients do not feel pain (due to
Polyol Pathway).

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Galactosemia:

Lactose intolerance is inability to digest lactose in digestive tract.

However, some people can digest lactose into glucose and galactose and
then absorb them but when galactose enters the cells, it cannot be
metabolized and then we will have a problem.

Clinical cases:

 Galactosemia

An apparently normal baby began to vomit and develop diarrhea after

breastfeeding. These problems, together with dehydration continued for
several days, when the baby began to refuse food and developed jaundice,
indicative of liver damage, followed by hepatomegaly and then lens
opacification (cataracts). Measurements of glucose in the blood and urine
by specific enzymatic technique indicated that levels of glucose were
low, consistent with the failure to absorb foods.

 Note that: we can measure blood sugar level by 2 ways:

1- Measuring blood by Glucokinase enzyme, which is specific for
glucose, and will give only glucose level in the blood.
2- Measuring blood by hexokinase enzyme, which is for all sugars,
and give all sugar level in the blood.

However glucose measured by a test that determined total reducing sugar

was eventually identified as galactose, indicating an abnormality in
galactose mechanism known as galactosemia. This finding was consistent
with the observation that, when milk was removed from the diet and
replaced with an infant formula containing sucrose rather than lactose, the
vomiting and diarrhea stopped, and hepatic function was gradually
restored.

 Remember that in galactose metabolism the most important

enzyme is uridyl transferase.

Comment: The accumulation of galactose in the blood is most often a

result of deficiency of Gal-1- P uridyl transferase in liver tissues.
Accumulation of the latter interferes with phosphate and glucose

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metabolism, leading to widespread tissue damage, organ failure, and

mental retardation.

 Remember that: when galactose enters the liver it will be

converted into galactose phosphate by galactokinase. Then,
galactose phosphate converted into UDP galactose and then to
UDP glucose by uridyl transferase. But in case of uridyl
transferase deficiency all galactose will be converted into
galactose phosphate and stop. By this mechanism, the inorganic
phosphate in within the liver is depleted. In this case,
glycogenolysis will be affected because it depends on
glycogenphosphrylase which break glycosidic bond by addition of
inorganic phosphate (from lec.2). But there is no inorganic
phosphate. So, glucose level will be affected. Because of this the
blood glucose level of the patient was low.
 Summary: Galactosemia due to deficiency of uridyl transferase
will affect blood glucose level.
 There is another type of galactosemia which is due to deficiency
of galactokinase. This type is milder than the first one because
galactose will not be converted into galactose phosphate in the
liver. So, glycogenolysis will not be affected and blood glucose
level also not affected.

 Finally: the 2 types of galactosemia are:

1. galactosemia due to deficiency of uridyl transferase.
2. galactosemia due to deficiency of galactokinase.

 Large Child Born of a Diabetic Mother:

A baby, born of poorly controlled, chronically hyperglycemic, diabetic

mother was large and chubby at birth (5kg.) (The normal is 3.5 kg) , but
appeared otherwise normal. He declined rapidly, however and, within 1
hour showed all of the symptoms of hypoglycemia, similar to the
previously described case of baby girl born of a malnourished mother.
The difference, in this case, is that the boy was thin, rather than heavy.

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Comments: this baby was exposed to a high blood glucose level inside
the uterus because of the placenta. As a response, the baby starts to
produce a huge amount of insulin and as you know that insulin is
anabolic hormone. Because of that the baby was large (5 KG). After
berth, he is normal and there is no hyperglycemia but he needs one week
or more to adapts with the normal case. So, he was showed all of the
symptoms of hypoglycemia.

 Fructose Intolerance:

An autosomal recessive condition, due to deficiency of fructose – 1-

phosphate aldolase.

The defect causes:

1. Intracellular accumulation of fructose -1- phosphate due to

deficiency of fructose – 1- phosphate aldolase. This also causes
depletion of inorganic phosphate in the liver.
2. Inhibition of fructokinase
3. Increased blood level of fructose.
4. Inhibition of glycogen phosphorylase due to depletion of inorganic
phosphate in the liver.
5. Profound hypoglycemia because of inhibition of glycogenolysis.

 Glycogen Storage Diseases:

There are 15 diseases known as glycogen storage diseases caused by

an abnormality of glycogen metabolism

3 of these are common in this region inside KSA which are:

I. Von Gierk’s Disease: ( case study )

 Major complaints:

A baby girl is irritable, sweaty and lethargic (tiered) and demands

food frequently.

 Physical examination:

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It was observed that she had an extended abdomen, resulting from

enlarged liver. Blood glucose, after a meal was 3.5mmol/l
(70mg/dl) (it should be at least 110 or 100 after a meal). After 4 hours
the child was exhibiting irritability and sweating, her heart rate was
increased and blood glucose had declined to 2mmol/l (40 mg/dl).
These symptoms were corrected by feeding her. A liver biopsy
showed massive deposition of glycogen in the liver cytosol.

 Clues :

1. Sweaty : Meaning being under stress "epinephrine effect "

2. Lethargic: Means that there is no energy indicating glucose
absence.
3. Blood glucose, after a meal was (70mg/dl) & blood glucose after
4 hours of eating declining to (40mg/dl) indicate that she has
Clinical Hypoglycemia
4. Symptoms corrected by feeding her & hepatomegaly &
deposition of glycogen in the liver all: indicate that glucose
intake is normal but once it’s stored in the liver as glycogen it
cannot be degraded resulting in hepatomegaly due to
accumulation of glycogen in the liver.

 Biochemical explanation of Von Gierk’s Disease:

It’s due to absence of glucose 6 phosphatase, which inhibits 2 major

pathways that maintains blood glucose causing sever hypoglycemia:

1. Glycogenolysis :

 Break down of Glycogen is done by the adding phosphate to

form glucose-1-phosphate then converting it to glucose-6-
phosphste by mutase then by glucose-6-phosphatase we free
glucose from phosphate.
 In absence of Glucose 6 phosphatase we cannot free glucose
from phosphate to maintain blood glucose level.
 The Inorganic Phosphate will be depleted, meaning that we
can’t break more glycogen.

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2. Gluconeogenesis :

We start with lactate which forms Pyruvate which forms etc...

Forming fructose-6-phohosphate and finally forming glucose-6-
phosphate and again we need glucose-6-phosphatase to free the
glucose.

II. Pompe’s Disease

 A genetic recessive disorder, due to absence of lysosomal
glucosidase .
 Lysosomal glucosidase is found in the specifically in lysosomes of
myocardial cells, hepatocytes & muscle cells.
 General function of Lysosome is to degrade things getting inside the
cell in to detoxify the cells.
 The function of Lysosomal glucosidase is not involved in
glycogenlysis but is needed protect the lysosome and keep it intact
by this mechanism :
1. Lysosome also engulfs glycogen molecules that get inside the
cell.
2. They degrade glycogen by addition of water into glucose.
3. Glucose gets dispersed in the cytosol.
4. In the cytosol glucose is combined as glycogen again.
5. It leaves the cell
 Lysosomal glucosidase deficiency :
1. When glycogen gets inside the cells, Lysosome will engulf it
2. It will not degrade it because of Lysosomal glucosidase
deficiency.
3. Glycogen will stay inside the lysosome.
4. Lysosome will keep engulfing glycogen molecules and getting
larger till it reaches a stage where lysosome membrane becomes
so fragile.
5. Finally lysosome’s membrane will rupture, releasing it lipolytic
, proteolytic, etc..lytic enzymes which will destroy the
organelles inside the cell resulting in the death of the cell

 So if this deficiency takes place in the heart muscles it will lead to

severe Cardiovascular disease, cardiomegaly precisely, and early
death due to heart attack.

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III. McArdle’s Disease:

 Major complaints:

A 30 year old man complains of chronic arm and leg muscle pain
and cramps during exercise. The pain generally disappears after about
15- 30 minutes, and then he could continue his exercise without
discomfort.

 Examination:

It was observed that his blood glucose level was normal during
exercise, but his serum creatine kinase (MM) was elevated. Blood
glucose declined slightly during exercise, but unexpectedly blood lactate
also declined, rather than increased, even when he was experiencing
muscle cramp. A biopsy indicated an unusually high level of glycogen in
muscle.

 Creatine Kinase is found in 3 forms :

1. Creatine Kinase (MM) found in the muscle

2. Creatine Kinase (BB) found in the Brain
3. Creatine Kinase (MB) found in the Heart
 One of the major Cardiac Markers is Ceatine Kinase ( MB )

 Creatine kinase is found in 3 forms:

1. CK-MM: in the muscles
2. CK-BB: in the brain
3. CK-MD: in the heart

 The elevated CK-MM indicates problems in the skeletal muscles.

 This patient suffers from rare deficiency of muscle phosphorylase
activity, an enzyme used to break down the glycogen into glucose in the
muscles.
→ As a result, we can't get glucose from glycogenolysis in the
muscles.
 Because muscle glycolysis doesn't contribute to the blood glucose level.
In addition, the liver's glycolysis isn't affected and the gluconeogenesis
is working properly.
→ Resulting in normal blood glucose level.

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 To conclude, this type of glucose disease doesn't affect the blood

glucose level; it only affects glycogenolysis in the muscles- mostly in
exercise.

The pentose phosphate pathway (hexose monophosphate shunt)

 Functions:
1. Production of Pentoses and Riboses (which are poorly absorbed in
the body).
2. Generate 100% of the reducing agent NADPH.

 It has 2 important enzymes:

1. Glucose 6-phosphate dehydrogenase (G6PD): converts glucose
6-phosphat into 6-phosphogluconat and produces 50% of NADPH.
2. 6-phosphogluconate dehydrogenase: converts 6-
phosphogluconate to ribulose and the other 50% of NADPH.

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Glucose 6 Phosphate Dehydrogenase Deficiency

"Just prior to a planned departure to the tropics, a patient visits his

physician, complaining of weakness and noting that his urine had recently
become unexplainably dark. Physical examination revealed slightly
jaundiced (yellow, icteric) sclera. Laboratory tests indicated a low
hematocrit, a high reticulocyte count, and significantly increased blood
level of bilirubin. The patient has been quite healthy during a previous
visit a month ago when he received immunizations and prescriptions for
drugs related to his travel plan."
 The diagnosis is Hemolytic Anemia.

 The phospholipids and proteins in the RBC's membrane are usually in

the reduced form, but they become oxidized as they carry out their
functions – this is a normal situation.

 RBCs membrane

consist of 1-phospholipid 2- protein

both of them are usually in the reduced form

#as it carries-out its metabolic function the phospholipids and proteins

become oxidized

The body reduce them again (giving them electrons from reduced
glutathione "GSH")

Giving its own electrons GSH becomes oxidized into oxidized glutathion
"GSSG"

so it needs To be reduced it would get its electrons from "NADPH"

giving its electrons NADPH would turn into NADP this you have to
reveres back into the reduced form "glucose-6-phosphate" into "6-
phosphogluconate" by the enzyme "G-6-P"

*now if the patient has G-6-P deficiency that means he doesn't have
enough NADPH that means he doesn't have enough GSH that means the

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body can't maintain the phospholipids and protein in the reduced form
making the RBCs membrane fragile and leading to hemolytic anemia

**the patient didn't have any symptoms of G6PD before taking the
medication prescribed which was (pamaquine)

(Pamaquine is known as Oxidizing agent)

The patient had deficiency of G6PD not absence so if you measure the
activity of G6PD it would be around 3-5%

Giving "pamaquine" to a normal person that would increase the rate of

oxidation and the body would increase the activity of G6PD to meet the
demand but a patient suffering from G6PD deficiency wouldn't

So patients with G6PD deficiency wouldn't show symptoms till the

encounter situations such as (stress, drugs , strenuous exercise)

 Favism :-

In the beans there is a chemical substance called tibicen that is

metabolized in the liver and have the same impact as pamaquine

Not all patients that have G6PD have favism

But all the patents that have favism has G6PD

 Genetically :-

The G6PD deficiency gene is on the X chromosome

So for the males it is either (XY) normal or (XY)abnormal

For the Females it is either (XX) normal or( XX) carrier or (XX)
abnormal

Know that it should be known that G6PD is sex chromosome linked

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