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Harper's Illustrated Biochemistry, 32e

Chapter 22: Oxidation of Fatty Acids: Ketogenesis

Kathleen M. Botham; Peter A. Mayes

OBJECTIVES

OBJECTIVES

After studying this chapter, you should be able to:

Describe the processes by which fatty acids are transported in the blood, activated and transported into the matrix of the mitochondria for
breakdown to obtain energy.

Outline the β­oxidation pathway by which fatty acids are metabolized to acetyl­CoA and explain how this leads to the production of large
quantities of ATP.

Identify the three compounds termed “ketone bodies” and describe the reactions by which they are formed in liver mitochondria.

Recognize that ketone bodies are important fuels for extrahepatic tissues and indicate the conditions in which their synthesis and use are
favored.

Indicate the three stages in the metabolism of fatty acids where ketogenesis is regulated.

Indicate that overproduction of ketone bodies leads to ketosis and, if prolonged, ketoacidosis, and identify pathologic conditions when this
occurs.

Give examples of diseases associated with impaired fatty acid oxidation.

BIOMEDICAL IMPORTANCE
Fatty acids are broken down in mitochondria by oxidation to acetyl­CoA in a process that generates large amounts of energy. When this pathway is
proceeding at a high rate, three compounds, acetoacetate, D ­3­hydroxybutyrate, and acetone, known collectively as the ketone bodies, are
produced by the liver. Acetoacetate and D­3­hydroxybutyrate are used as fuels by extrahepatic tissues in normal metabolism, but overproduction of
ketone bodies causes ketosis. Increased fatty acid oxidation and consequently ketosis is a characteristic of starvation and of diabetes mellitus. Since
ketone bodies are acidic, when they are produced in excess over long periods, as in diabetes, they cause ketoacidosis, which is potentially life­
threatening. Because gluconeogenesis is dependent on fatty acid oxidation, any impairment in fatty acid oxidation leads to hypoglycemia. This
occurs in various states of carnitine deficiency or deficiency of essential enzymes in fatty acid oxidation, for example, carnitine
palmitoyltransferase, or inhibition of fatty acid oxidation by poisons, for example, hypoglycin.

OXIDATION OF FATTY ACIDS OCCURS IN MITOCHONDRIA

Although acetyl­CoA is both an end point of fatty acid catabolism and the starting substrate for fatty acid synthesis, breakdown is not simply the
reverse of the biosynthetic pathway, but an entirely separate process taking place in a different compartment of the cell. The separation of fatty acid
oxidation in mitochondria from biosynthesis in the cytosol allows each process to be individually controlled and integrated with tissue requirements.
Each step in fatty acid oxidation involves acyl­CoA derivatives, is catalyzed by separate enzymes, utilizes NAD+ and FAD as coenzymes, and generates
ATP. It is an aerobic process, requiring the presence of oxygen.
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Fatty Acids Are
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Free fatty acids (FFAs)—also called unesterified (UFA) or nonesterified (NEFA) fatty acids (see Chapter 21)—are fatty acids that are in the unesterified
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Although acetyl­CoA is both an end point of fatty acid catabolism and the starting substrate for fatty acid synthesis, breakdown Peruana
is notCayetano
simply theHeredia
reverse of the biosynthetic pathway, but an entirely separate process taking place in a different compartment Access
of theProvided
cell. The
by: separation of fatty acid

oxidation in mitochondria from biosynthesis in the cytosol allows each process to be individually controlled and integrated with tissue requirements.
Each step in fatty acid oxidation involves acyl­CoA derivatives, is catalyzed by separate enzymes, utilizes NAD+ and FAD as coenzymes, and generates
ATP. It is an aerobic process, requiring the presence of oxygen.

Fatty Acids Are Transported in the Blood as Free Fatty Acids

Free fatty acids (FFAs)—also called unesterified (UFA) or nonesterified (NEFA) fatty acids (see Chapter 21)—are fatty acids that are in the unesterified
state. In plasma, longer­chain FFA are combined with albumin, and in the cell they are attached to a fatty acid–binding protein, so that in fact they
are never really “free.” Shorter­chain fatty acids are more water soluble and exist as the unionized acid or as a fatty acid anion.

Fatty Acids Are Activated Before Being Catabolized

Fatty acids must first be converted to an active intermediate before they can be catabolized. This is the only step in the complete degradation of a fatty
acid that requires energy from ATP. In the presence of ATP and coenzyme A, the enzyme acyl­CoA synthetase (thiokinase) catalyzes the conversion
of a fatty acid (or FFA) to an “active fatty acid” or acyl­CoA, using one high­energy phosphate and forming AMP and PPi (Figure 22–1). The PPi is
hydrolyzed by inorganic pyrophosphatase with the loss of a further high­energy phosphate, ensuring that the overall reaction goes to completion.
Acyl­CoA synthetases are found on the outer membrane of mitochondria and also in the endoplasmic reticulum and peroxisomes.

FIGURE 22–1

Role of carnitine in the transport of long­chain fatty acids through the inner mitochondrial membrane. Long­chain acyl­CoA formed by
acyl­CoA synthetase enters the intermembrane space. For transport across the inner membrane, acyl groups must be transferred from CoA to carnitine
by carnitine palmitoyltransferase­I. The acylcarnitine formed is then carried into the matrix by a translocase enzyme in exchange for a free carnitine
and acyl­CoA is reformed by carnitine palmitoyltransferase­II.

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Chapter 22: Oxidation
Long­Chain Fatty of Fatty Cross
Acids Acids: Ketogenesis, Kathleen M. Botham;
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Acyl­CoAs formed as described earlier enter the intermembrane space (see Figure 22–1), but are unable to cross the inner mitochondrial membrane
into the matrix where fatty acid breakdown takes place. In the presence of carnitine (β­hydroxy­γ­trimethylammonium butyrate), a compound widely
Role of carnitine in the transport of long­chain fatty acids through the inner mitochondrial membrane. Long­chain acyl­CoA formed by
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acyl­CoA synthetase enters the intermembrane space. For transport across the inner membrane, acyl groups must be transferred from CoA to carnitine
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by carnitine palmitoyltransferase­I. The acylcarnitine formed is then carried into the matrix by a translocase enzyme in exchange for a free carnitine
and acyl­CoA is reformed by carnitine palmitoyltransferase­II.

Long­Chain Fatty Acids Cross the Inner Mitochondrial Membrane as Carnitine Derivatives

Acyl­CoAs formed as described earlier enter the intermembrane space (see Figure 22–1), but are unable to cross the inner mitochondrial membrane
into the matrix where fatty acid breakdown takes place. In the presence of carnitine (β­hydroxy­γ­trimethylammonium butyrate), a compound widely
distributed in the body and particularly abundant in muscle; however, carnitine palmitoyltransferase­I, an enzyme located in the outer
mitochondrial membrane, transfers the long­chain acyl group from CoA to carnitine, forming acylcarnitine and releasing CoA. Acylcarnitine is able to
penetrate the inner membrane and gain access to the β­oxidation system of enzymes via the inner membrane exchange transporter carnitine­
acylcarnitine translocase. The transporter binds acylcarnitine and transports it across the membrane in exchange for carnitine. The acyl group is
then transferred to CoA so that acyl­CoA is reformed and carnitine is liberated. This reaction is catalyzed by carnitine palmitoyltransferase­II,
which is located on the inside of the inner membrane (see Figure 22–1).

β­OXIDATION OF FATTY ACIDS INVOLVES SUCCESSIVE CLEAVAGE WITH RELEASE OF ACETYL­

COA
In the pathway for the oxidation of fatty acids (Figure 22–2), two carbons at a time are cleaved from acyl­CoA molecules, starting at the carboxyl end.
The chain is broken between the α(2)­ and β(3)­carbon atoms—hence the process is termed β­oxidation. The two­carbon units formed are acetyl­
CoA; thus, palmitoyl(C16)­CoA forms eight acetyl­CoA molecules.

FIGURE 22–2

Overview of β­oxidation of fatty acids.

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The chain is broken between the α(2)­ and β(3)­carbon atoms—hence the process is termed β­oxidation. The two­carbon units formed are acetyl­
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CoA; thus, palmitoyl(C16)­CoA forms eight acetyl­CoA molecules.
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FIGURE 22–2

Overview of β­oxidation of fatty acids.

The β­Oxidation Cycle Generates FADH2 & NADH

Several enzymes found in the mitochondrial matrix or inner membrane adjacent to the respiratory chain catalyze the oxidation of acyl­CoA to acetyl­
CoA via the β­oxidation pathway. The system proceeds in cyclic fashion which results in the degradation of long fatty acids to acetyl­CoA. In the
process, large quantities of the reducing equivalents FADH2 and NADH are generated and are used to form ATP by oxidative phosphorylation (see
Chapter 13) (Figure 22–3).

FIGURE 22–3

β­Oxidation of fatty acids. Long­chain acyl­CoA is cycled through reactions

to
, acetyl­CoA being split off, each cycle, by thiolase (reaction
). When the acyl radical is only four carbon atoms in length, two acetyl­CoA molecules are formed in reaction
.

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The first step is the removal of two hydrogen atoms from the 2(α)­ and 3(β)­carbon atoms, catalyzed by acyl­CoA dehydrogenase and requiring
flavin adenine dinucleotide (FAD). This results in the formation of Δ2­trans­enoyl­CoA and FADH2. Next, water is added to saturate the double bond and

form 3­hydroxyacyl­CoA, catalyzed by Δ2­enoyl­CoA hydratase. The 3­hydroxy derivative undergoes further dehydrogenation on the 3­carbon
catalyzed by L­3­hydroxyacyl­CoA dehydrogenase to form the corresponding 3­ketoacyl­CoA compound. In this case, NAD+ is the coenzyme
involved. Finally, 3­ketoacyl­CoA is split at the 2,3­position by thiolase (3­ketoacyl­CoA­thiolase), forming acetyl­CoA and a new acyl­CoA two carbons
shorter than the original acyl­CoA molecule. The shorter acyl­CoA formed in the cleavage reaction reenters the oxidative pathway at reaction 2 (see
Figure 22–3). In this way, a long­chain fatty acid with an even number of carbons may be degraded completely to acetyl­CoA (C2 units). For example,
after seven cycles, the C16 fatty acid, palmitate, would be converted to eight acetyl­CoA molecules. Since acetyl­CoA can be oxidized to CO2 and water
via the citric acid cycle (which is also found within the mitochondria), the complete oxidation of fatty acids is achieved.

Fatty acids with an odd number of carbon atoms are oxidized by the pathway of β­oxidation described earlier, producing acetyl­CoA until a three­
carbon (propionyl­CoA) residue remains. This compound is converted to succinyl­CoA, a constituent of the citric acid cycle (see Chapter 16). Hence, the
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an odd­chain is 50.112.82.0
acid is the only part of a fatty acid that is glucogenic.
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Oxidation of Fatty Acids Produces a Large Quantity of ATP

Each cycle of β­oxidation generates one molecule of FADH and one of NADH. The breakdown of 1 mol of the C16 fatty acid, palmitate, requires seven
Figure 22–3). In this way, a long­chain fatty acid with an even number of carbons may be degraded completely to acetyl­CoA (C2 units). For example,
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after seven cycles, the C16 fatty acid, palmitate, would be converted to eight acetyl­CoA molecules. Since acetyl­CoA can be Peruana Cayetano
oxidized to Heredia
CO and water 2
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via the citric acid cycle (which is also found within the mitochondria), the complete oxidation of fatty acids is achieved.

Fatty acids with an odd number of carbon atoms are oxidized by the pathway of β­oxidation described earlier, producing acetyl­CoA until a three­
carbon (propionyl­CoA) residue remains. This compound is converted to succinyl­CoA, a constituent of the citric acid cycle (see Chapter 16). Hence, the
propionyl residue from an odd­chain fatty acid is the only part of a fatty acid that is glucogenic.

Oxidation of Fatty Acids Produces a Large Quantity of ATP

Each cycle of β­oxidation generates one molecule of FADH2 and one of NADH. The breakdown of 1 mol of the C16 fatty acid, palmitate, requires seven
cycles and produces 8 mol of acetyl­CoA. Oxidation of the reducing equivalents via the respiratory chain leads to the synthesis of 28 mol of ATP (Table
22–1 and see Chapter 13) and oxidation of acetyl­CoA via the citric acid cycle produces 80 mol of ATP (see Table 22–1 and Chapter 16). The breakdown
of 1 mol of palmitate, therefore, yields a gross total of 108 mol of ATP. However, two high­energy phosphates are used in the initial activation step (see
Figure 22–3), thus there is a net gain of 106 mol of ATP per mole of palmitate used (see Table 22–1), or 106 × 30.5* = 3233 kJ. This represents 33% of the
free energy of combustion of palmitic acid.

TABLE 22–1
Generation of ATP From the Complete Oxidation of a C16 Fatty Acid

Amount Product Formed ATP Formed Total ATP Formed ATP Used (mol)/mol
Step Product
(mol)/mol Palmitate (mol)/mol Product (mol)/mol Palmitate Palmitate

Activation – 2

β­ FADH2 7 1.5 10.5 –

Oxidation

β­ NADH 7 2.5 17.5 –

Oxidation

Citric acid Acetyl­ 8 10 80 –

cycle CoA

Total ATP formed (mol)/mol palmitate 108

Total ATP used (mol)/mol palmitate 2

The table shows how the oxidation of 1 mol of the C16 fatty acid, palmitate, generates 106 mol of ATP (108 formed in total—2 used in the activation step).

Peroxisomes Oxidize Very­Long­Chain Fatty Acids

A modified form of β­oxidation is found in peroxisomes and leads to the breakdown of very­long­chain fatty acids (eg, C20, C22) with the formation of
acetyl­CoA and H2O2, which is broken down by catalase (see Chapter 12). This system, however, is not linked directly to phosphorylation and the
generation of ATP. The peroxisomal enzymes are induced by high­fat diets and in some species by hypolipidemic drugs such as clofibrate.

Another role of peroxisomal β­oxidation is to shorten the side chain of cholesterol in bile acid formation (see Chapter 26). Peroxisomes also take part
in the synthesis of ether glycerolipids (see Chapter 24), cholesterol, and dolichol (see Figure 26–2).

Oxidation of Unsaturated Fatty Acids Occurs by a Modified β­Oxidation Pathway

The CoA esters of unsaturated fatty acids are degraded by the enzymes normally responsible for β­oxidation until there is a cis double bond in the Δ3
or Δ4 position (Figure 22–4). A Δ3­cis compound is isomerized (Δ 3cis → Δ 2­ trans­enoyl­CoA isomerase) to the corresponding Δ2­trans­CoA stage
of β­oxidation for subsequent hydration and oxidation. Any Δ4­cis­acyl­CoA either remaining, as in the case of linoleic acid (shown in Figure 22–4), or
entering the pathway
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Yourconversion by acyl­CoA dehydrogenase to Δ2­trans­Δ4­cis­dienoyl­CoA, is then metabolized as indicated in
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Figure 22–4. Page 6 / 14
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FIGURE 22–4
Oxidation of Unsaturated Fatty Acids Occurs by a Modified β­Oxidation Pathway
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The CoA esters of unsaturated fatty acids are degraded by the enzymes normally responsible for β­oxidation until
Accessthere a cis double bond in the Δ3
is by:
Provided

or Δ4 position (Figure 22–4). A Δ3­cis compound is isomerized (Δ 3cis → Δ 2­ trans­enoyl­CoA isomerase) to the corresponding Δ2­trans­CoA stage
of β­oxidation for subsequent hydration and oxidation. Any Δ4­cis­acyl­CoA either remaining, as in the case of linoleic acid (shown in Figure 22–4), or
entering the pathway at this point after conversion by acyl­CoA dehydrogenase to Δ2­trans­Δ4­cis­dienoyl­CoA, is then metabolized as indicated in
Figure 22–4.

FIGURE 22–4

Sequence of reactions in the oxidation of unsaturated fatty acids, for example, linoleic acid. β­Oxidation proceeds as for saturated fatty
acids until there is a cis double bond in the Δ3 position. This is then isomerized to the corresponding Δ2­trans compound allowing one cycle of β­
oxidation to proceed, producing the Δ2­ trans­ Δ4­cis derivative. Δ4­cis­fatty acids or fatty acids forming Δ4­cis­enoyl­CoA enter the pathway here. A
reduction step forming Δ3­trans­enoyl­CoA followed by an isomerization to the Δ2­trans form is required to enable β­oxidation to then go to
completion. NADPH for the dienoyl­CoA reductase step is supplied by intramitochondrial sources such as glutamate dehydrogenase, isocitrate
dehydrogenase, and NAD(P)H transhydrogenase.

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*ΔG for the ATP reaction, as explained in Chapter 11.

KETOGENESIS OCCURS WHEN THERE IS A HIGH RATE OF FATTY ACID OXIDATION IN THE
LIVER
Under metabolic conditions associated with a high rate of fatty acid oxidation, the liver produces considerable quantities of acetoacetate and D­3­
hydroxybutyrate (3­hydroxybutyrate or β­hydroxybutyrate). Acetoacetate continually undergoes spontaneous decarboxylation to yield acetone.
These three substances are collectively known as the ketone bodies (also called acetone bodies or [incorrectly*] “ketones”) (Figure 22–5).
Acetoacetate and 3­hydroxybutyrate are interconverted by the mitochondrial enzyme D­3­hydroxybutyrate dehydrogenase; the equilibrium is
controlled by the mitochondrial [NAD+]/[NADH] ratio, that is, the redox state. The concentration of total ketone bodies in the blood of well­fed
mammals does not normally exceed 0.2 mmol/L. However, in ruminants, 3­hydroxybutyrate is formed continuously from butyric acid (a product of
ruminal fermentation) in the rumen wall. In nonruminants, the liver appears to be the only organ that adds significant quantities of ketone bodies to
the blood. Extrahepatic tissues utilize acetoacetate and 3­hydroxybutyrate as respiratory substrates. Acetone is a waste product which, as it is volatile,
can be excreted via the lungs. Because there is active synthesis but little utilization of ketone bodies in the liver, while they are used but not produced in
extrahepatic tissues, there is a net flow of the compounds to the extrahepatic tissues (Figure 22–6).

FIGURE 22–5

Interrelationships of the ketone bodies. D­3­Hydroxybutyrate dehydrogenase is a mitochondrial enzyme.

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Formation, utilization, and excretion of ketone bodies. (The main pathway is indicated by the solid arrows.)
extrahepatic tissues, there is a net flow of the compounds to the extrahepatic tissues (Figure 22–6).
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FIGURE 22–5
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Interrelationships of the ketone bodies. D­3­Hydroxybutyrate dehydrogenase is a mitochondrial enzyme.

FIGURE 22–6

Formation, utilization, and excretion of ketone bodies. (The main pathway is indicated by the solid arrows.)

Acetoacetyl­CoA Is the Substrate for Ketogenesis

The enzymes responsible for ketone body formation (ketogenesis) are associated mainly with the mitochondria. Acetoacetyl­CoA is formed when two
acetyl­CoA molecules produced via fatty acid breakdown condense to form acetoacetyl­CoA by a reversal of the thiolase reaction (see Figure 22–3),
and may also arise directly from the terminal four carbons of a fatty acid during β­oxidation (Figure 22–7). Condensation of acetoacetyl­CoA with
another molecule of acetyl­CoA by 3­hydroxy­3­methylglutaryl­CoA (HMG­CoA) synthase forms HMG­CoA. HMG­CoA lyase then causes acetyl­
CoA to split off from the HMG­CoA, leaving free acetoacetate. Both enzymes must be present in mitochondria for ketogenesis to take place.
In mammals, ketone bodies are formed solely in the liver and in the rumen epithelium. 3­Hydroxybutyrate is formed from acetoacetate (see Figure 22–
7) and is quantitatively the predominant ketone body present in the blood and urine in ketosis.

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Pathways of ketogenesis in the liver. (FFA, free fatty acids.)
and may also arise directly from the terminal four carbons of a fatty acid during β­oxidation (Figure 22–7). Condensation of acetoacetyl­CoA with
another molecule of acetyl­CoA by 3­hydroxy­3­methylglutaryl­CoA (HMG­CoA) synthase forms HMG­CoA. HMG­CoA
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Cayetano acetyl­
CoA to split off from the HMG­CoA, leaving free acetoacetate. Both enzymes must be present in mitochondria for ketogenesis
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In mammals, ketone bodies are formed solely in the liver and in the rumen epithelium. 3­Hydroxybutyrate is formed from acetoacetate (see Figure 22–
7) and is quantitatively the predominant ketone body present in the blood and urine in ketosis.

FIGURE 22–7

Pathways of ketogenesis in the liver. (FFA, free fatty acids.)

Ketone Bodies Serve as a Fuel for Extrahepatic Tissues

While an active enzymatic mechanism produces acetoacetate from acetoacetyl­CoA in the liver, acetoacetate once formed can only be reactivated by
linkage to CoA directly in the cytosol, where it is used in a different, much less active pathway as a precursor in cholesterol synthesis (see Chapter 26).
This accounts for the net production of ketone bodies by the liver.

In extrahepatic tissues, acetoacetate is activated to acetoacetyl­CoA by succinyl­CoA­acetoacetate­CoA transferase. CoA is transferred from
succinyl­CoA to form acetoacetyl­CoA (Figure 22–8). In a reaction requiring the addition of a CoA, two acetyl­CoA molecules are formed by the
splitting of acetoacetyl­CoA by thiolase and these are oxidized in the citric acid cycle. 3­Hydroxybutyrate is utilized by conversion to acetoacetate by the
reversal of the reaction by which it is formed in the liver, generating an NADH in the process (see Figure 22–8). Thus, 1 mol of acetoacetate or 3­
hydroxbutyrate yields 19 or 21.5 mol of ATP, respectively, by these pathways. If the blood level of ketone bodies rises to a concentration of ~12 mmol/L,
the oxidative machinery becomes saturated and at this stage, a large proportion of oxygen consumption may be accounted for by their oxidation.

FIGURE 22–8

Transport of ketone bodies from the liver and pathways of utilization and oxidation in extrahepatic tissues. CoA transferase, succinyl­
CoA­acetoacetate­CoA transferase. The breakdown of acetoacetyl­CoA by thiolase produces two acetyl­CoA molecules and requires the addition of one
CoA (not shown).

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FIGURE 22–8

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Transport of ketone bodies from the liver and pathways of utilization and oxidation in extrahepatic tissues. CoA transferase, succinyl­
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CoA­acetoacetate­CoA transferase. The breakdown of acetoacetyl­CoA by thiolase produces two acetyl­CoA molecules and requires the addition of one
CoA (not shown).

In moderate ketonemia, the loss of ketone bodies via the urine is only a few percent of the total ketone body production and utilization. Since there are
renal threshold­like effects (there is not a true threshold) that vary between species and individuals, measurement of the ketonemia, not the ketonuria,
is the preferred method of assessing the severity of ketosis.

*The term ketones should not be used as there are ketones in blood that are not ketone bodies, for example, pyruvate and fructose.

KETOGENESIS IS REGULATED AT THREE CRUCIAL STEPS

1. Ketosis does not occur in vivo unless there is an increase in the level of circulating FFAs arising from lipolysis of triacylglycerol in adipose tissue.
FFAs are the precursors of ketone bodies in the liver. Both in fed and in fasting conditions, the liver extracts ~30% of the FFAs passing
through it, so that at high concentrations the flux passing into the organ is substantial. Thus, the factors regulating mobilization of FFA
from adipose tissue are important in controlling ketogenesis (Figures 22–9 and 25–8).

2. After uptake by the liver, FFAs are either oxidized to CO2 or ketone bodies or esterified to triacylglycerol and phospholipid (acylglycerols). There
is regulation of entry of fatty acids into the oxidative pathway by carnitine palmitoyltransferase­I (CPT­I) (see Figure 22–1), and the remainder
of the fatty acid taken up is esterified. CPT­I activity is low in the fed state, leading to depression of fatty acid oxidation, and high in starvation,
allowing fatty acid oxidation to increase. Malonyl­CoA, the initial intermediate in fatty acid biosynthesis (see Figure 23–1) is a potent inhibitor of
CPT­I (Figure 22–10). In the fed state, therefore, FFAs enter the liver cell in low concentrations and are nearly all esterified to acylglycerols and
transported out of the liver in very­low­density lipoprotein (VLDL). However, as the concentration of FFA increases with the onset of starvation,
acetyl­CoA carboxylase is inhibited directly by acyl­CoA, and (malonyl­CoA) decreases, releasing the inhibition of CPT­I and allowing more acyl­CoA
to be β­oxidized. These events are reinforced in starvation by a decrease in the (insulin) / (glucagon) ratio. Thus, β­oxidation from FFA is
controlled by the CPT­I gateway into the mitochondria, and the balance of the FFA uptake not oxidized is esterified.

3. In turn, the acetyl­CoA formed in β­oxidation is oxidized in the citric acid cycle, or it enters the pathway of ketogenesis via acetoacetyl­CoA to form
ketone bodies. As the level of serum FFA is raised, proportionately more of the acetyl­CoA produced from their breakdown is converted to ketone
bodies and less is oxidized via the citric acid cycle to CO2. The partition of acetyl­CoA between the ketogenic pathway and the pathway of oxidation
to CO2 is regulated so that the total free energy captured in ATP which results from the oxidation of FFA remains constant as their concentration in
the serum changes. This may be appreciated when it is realized that complete oxidation of 1 mol of palmitate involves a net production of 106 mol
of ATP via β­oxidation and the citric acid cycle (see earlier), whereas only 26 mol of ATP are produced when acetoacetate is the end product and
only 16 mol when 3­hydroxybutyrate is the end product. Thus, ketogenesis may be regarded as a mechanism that allows the liver to oxidize
increasing quantities of fatty acids within the constraints of a tightly coupled system of oxidative phosphorylation.

FIGURE 22–9

Regulation of ketogenesis.
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show three crucial steps in the pathway of metabolism of free fatty acids (FFA) that determine the extent of ketogenesis. (CPT­I, carnitine
palmitoyltransferase­I.)
 only 16 mol when 3­hydroxybutyrate is the end product. Thus, ketogenesis may be regarded as a mechanism that allows the liver to oxidize
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increasing quantities of fatty acids within the constraints of a tightly coupled system of oxidative phosphorylation.
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FIGURE 22–9

Regulation of ketogenesis.

to
show three crucial steps in the pathway of metabolism of free fatty acids (FFA) that determine the extent of ketogenesis. (CPT­I, carnitine
palmitoyltransferase­I.)

FIGURE 22–10

Regulation of long­chain fatty acid oxidation in the liver. (FFA, free fatty acids; VLDL, very­low­density lipoprotein.) Positive (

) and negative (
) regulatory effects are represented by broken arrows and substrate flow by solid arrows.

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FIGURE 22–10

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Regulation of long­chain fatty acid oxidation in the liver. (FFA, free fatty acids; VLDL, very­low­density Access
lipoprotein.)
Provided by:Positive (

) and negative (
) regulatory effects are represented by broken arrows and substrate flow by solid arrows.

A fall in the concentration of oxaloacetate, particularly within the mitochondria, can impair the ability of the citric acid cycle to metabolize acetyl­CoA
and divert fatty acid oxidation toward ketogenesis. Such a fall may occur because of an increase in the (NADH)/(NAD+) ratio caused when increased β­
oxidation alters the equilibrium between oxaloacetate and malate so that the concentration of oxaloacetate is decreased, and also when
gluconeogenesis is elevated due to low blood glucose levels. The activation by acetyl­CoA of pyruvate carboxylase, which catalyzes the conversion of
pyruvate to oxaloacetate, partially alleviates this problem, but in conditions such as starvation and untreated diabetes mellitus, ketone bodies are
overproduced and cause ketosis.

CLINICAL ASPECTS
Impaired Oxidation of Fatty Acids Gives Rise to Diseases Often Associated With Hypoglycemia

Carnitine deficiency can occur particularly in the newborn—and especially in preterm infants—owing to inadequate biosynthesis or renal leakage.
Losses can also occur in hemodialysis. This suggests there may be a vitamin­like dietary requirement for carnitine in some individuals. Symptoms of
deficiency include hypoglycemia, which is a consequence of impaired fatty acid oxidation, and lipid accumulation with muscular weakness. Treatment
is by oral supplementation with carnitine.

Inherited CPT­I deficiency affects only the liver, resulting in reduced fatty acid oxidation and ketogenesis, with hypoglycemia. CPT­II deficiency
affects primarily skeletal muscle and, when severe, the liver. The sulfonylurea drugs (glyburide [glibenclamide] and tolbutamide), used in the
treatment of Type 2 diabetes mellitus, reduce fatty acid oxidation and, therefore, hyperglycemia by inhibiting CPT­I.

Inherited defects in the enzymes of β­oxidation and ketogenesis also lead to nonketotic hypoglycemia, coma, and fatty liver. Defects have been
identified in long­ and short­chain 3­hydroxyacyl­CoA dehydrogenase (deficiency of the long­chain enzyme may be a cause of acute fatty liver of
pregnancy). 3­Ketoacyl­CoA thiolase and HMG­CoA lyase deficiency also affect the degradation of leucine, a ketogenic amino acid (see Chapter
29).

Jamaican vomiting sickness is caused by eating the unripe fruit of the akee tree, which contains the toxin hypoglycin. This inactivates medium­
and short­chain acyl­CoA dehydrogenase, inhibiting β­oxidation and causing hypoglycemia. Dicarboxylic aciduria is characterized by the excretion
of C6—C10 ω­dicarboxylic acids and by nonketotic hypoglycemia, and is caused by a lack of mitochondrial medium­chain acyl­CoA dehydrogenase.
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Refsum 22:
Chapter disease is a rare
Oxidation neurologic
of Fatty Acids:disorder causedKathleen
Ketogenesis, by a metabolic defectPeter
M. Botham; that results in the accumulation of phytanic acid, which is found
A. Mayes in 13
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effects on membrane function, protein prenylation, and gene
expression. Zellweger (cerebrohepatorenal) syndrome occurs in individuals with a rare inherited absence of peroxisomes in all tissues. They
accumulate C —C polyenoic acids in brain tissue and also exhibit a generalized loss of peroxisomal functions. The disease causes severe neurologic
pregnancy). 3­Ketoacyl­CoA thiolase and HMG­CoA lyase deficiency also affect the degradation of leucine, a ketogenic amino acid (see Chapter
Universidad Peruana Cayetano Heredia
29).
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Jamaican vomiting sickness is caused by eating the unripe fruit of the akee tree, which contains the toxin hypoglycin. This inactivates medium­
and short­chain acyl­CoA dehydrogenase, inhibiting β­oxidation and causing hypoglycemia. Dicarboxylic aciduria is characterized by the excretion
of C6—C10 ω­dicarboxylic acids and by nonketotic hypoglycemia, and is caused by a lack of mitochondrial medium­chain acyl­CoA dehydrogenase.
Refsum disease is a rare neurologic disorder caused by a metabolic defect that results in the accumulation of phytanic acid, which is found in dairy
products and ruminant fat and meat. Phytanic acid is thought to have pathologic effects on membrane function, protein prenylation, and gene
expression. Zellweger (cerebrohepatorenal) syndrome occurs in individuals with a rare inherited absence of peroxisomes in all tissues. They
accumulate C26—C38 polyenoic acids in brain tissue and also exhibit a generalized loss of peroxisomal functions. The disease causes severe neurologic
symptoms, and most patients die in the first year of life.

Ketoacidosis Results From Prolonged Ketosis

Higher than normal quantities of ketone bodies present in the blood or urine constitute ketonemia (hyperketonemia) or ketonuria, respectively.
The overall condition is called ketosis. The basic form of ketosis occurs in starvation and involves depletion of available carbohydrate coupled with
mobilization of FFA. An exaggeration of this general pattern of metabolism produces the pathologic states found in diabetes mellitus, the type 2
form of which is increasingly common in Western countries; twin lamb disease; and ketosis in lactating cattle. Nonpathologic forms of
ketosis are found under conditions of high­fat feeding and after severe exercise in the postabsorptive state.

Acetoacetic and 3­hydroxybutyric acids are both moderately strong acids and are buffered when present in blood or other tissues. However, their
continual excretion in quantity progressively depletes the alkali reserve, causing ketoacidosis. This may be fatal in uncontrolled diabetes mellitus.

SUMMARY
Fatty acid oxidation in mitochondria leads to the generation of large quantities of ATP by a process called β­oxidation that cleaves acetyl­CoA units
sequentially from fatty acyl chains. The acetyl­CoA is oxidized in the citric acid cycle, generating further ATP.

The ketone bodies (acetoacetate, 3­hydroxybutyrate, and acetone) are formed in hepatic mitochondria when there is a high rate of fatty acid
oxidation. The pathway of ketogenesis involves synthesis and breakdown of HMG­CoA by two key enzymes: HMG­CoA synthase and HMG­CoA
lyase.

Ketone bodies are important fuels in extrahepatic tissues.

Ketogenesis is regulated at three crucial steps: (1) control of FFA mobilization from adipose tissue; (2) the activity of carnitine
palmitoyltransferase­I in liver, which determines the proportion of the fatty acid flux that is oxidized rather than esterified; and (3) partition of
acetyl­CoA between the pathway of ketogenesis and the citric acid cycle.

Diseases associated with impairment of fatty acid oxidation lead to hypoglycemia, fatty infiltration of organs, and hypoketonemia.

Ketosis is mild in starvation but severe in diabetes mellitus and ruminant ketosis.

REFERENCES

Eljamil AS: Lipid Biochemistry: For Medical Sciences . iUniverse, 2015.

Gurr MI, Harwood JL, Frayn KN, et al: Lipids, Biochemistry, Biotechnology and Health . Wiley­Blackwell 2016.

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