Systemic Carnitine Deficiency

CLINICAL CASE Patient Y - 3 yrs.old boy - From Chihuahua, Mexico - Non consaguineous Parents

3 MONTHS OLD
Coma Cardiac Arrest Hepatomegaly Cardiomegaly Hypotonia Blood Glucose Count 15 mg/dl 3rd of admission: Lethargic General Seizure

6 MONTHS OLD
CHF after URTI Hepatomegaly Hypotonia 3rd of admission: Lethargic General Seizure Cardiac Arrest Noted afterrecovery: Proximal Muscle Weakness Growth Retardation

20, 24 and 33 MONTHS OLD

Cardiorespi arrest after URTI Hepatomegaly 11th admission: Fatty changes in Liver Lack of ketone bodies after 24 hours Final Diagnosis: SYSTEMIC CARNITINE DEFICIENCY

Carnitine Synthesis

L lysine Glycine

3-hydroxy-trimethyl-L-lysine

4-trimethylammoniobutanal
H20 NAD+

N-trimethyllysine Hydroxylase L-carnitine Succinate CoA O2 2-oxoglutarate

2 H+ NADH

Y-Butyrobetaine

Carnitine Shuttle

FFA + Ac

FAC CYTOSOL

Acyl-CoA Synthetase

CPT I

OUTER MITOCHONDRIAL MEMBRANE

B-Oxidation
FAC Carnitine
CPT II Translocase

Acylcarnitine

INNER MTOCHONDRIAL MEMBRANE

Carnitine FAC Acylcarnitine

Carnitine
75% provided in diet; 25% synthesized in liver
CH3 O CH2 CH OH CH2 C O
-

- meat, poultry, fish & dairy products - 70 80% of dietary intake is absorbed

CH3 N

CH3

Carnitine is used to regulate levels of acyl-CoA inside cells - CoA pools are limited and CoA is needed in other processes (GNG, CAC, Urea cycle, F-ox) - Transfer acyl to carnitine to restore CoA pools so the acyl-carnitine serve as a reservoir of activated acyl groups.

Urea Cycle

regulated step

excreted in urine
*emphasis on green text added

To CAC
Adapted from http://web.indstate.edu/thcme/mwking/nitrogen-metabolism.html

carbamoyl phosphate synthetase-I activates acetyl-CoA + glutamate N-acetylglutamate + CoA

N-acetylglutamate synthetase

Without restoration of CoA pools, Acetyl-CoA levels drop N-acetylglutamate (NAG) will not be made CPS I will not be activated and so urea cycle will not proceed NH4+ builds up

Primary Carnitine Deficiency

also called  Systemic primary carnitine deficiency (CDSP)  Deficiency of plasma-membrane carnitine transporter  Carnitine transporter deficiency or carnitine uptake defect (CUD)

autosomal recessive metabolic disorder  prevents the body from using fats for energy, particularly during periods without food.
 Carnitine, a natural substance acquired mostly through diet, is used by cells to process fats and produce energy.

People with primary carnitine deficiency have:  defective proteins called carnitine transporters, which bring carnitine into cells and prevent its escape from the body.

Primary Carnitine Deficiency

aka Plasmalemmal Carnitine Transporter Defect cardiomyopathy (disease of heart muscle) Late infancy or early childhood (1 ~ 7 years)

hypoglycemic, hypoketotic encephalopathy (disorder of brain) 1 month ~ 5 years of age

responds to carnitine supplementation suspected compensation by other transporters

Primary Carnitine Deficiency

Defect in active transport of carnitine across the cell membrane from blood into cell by OCTN2 a member of the SLC22 family of transporters (1) renal reabsorption is impaired (2) tissues are unable to concentrate carnitine (heart, muscle, fibroblasts) reason limited improvement seen if plasma carnitine supplemented to normal (must be higher)

SLC22 Transporter Family

Eur J Physiol (2004) 447:666-676

1) Electrogenic 2) Na+ indep 3) reversible

1) OC uniport 2) H+/OC antiport *3) Na+/Carn cotrans

1) Reversible 2) Cotransport 3) Divalent OC

SLC22 Structural Topology/Similarity

Extracellular Glycosylated Domain, TMD 1 & 2
Eur J Physiol (2004) 447:666-676

Substrate Selectivity

12 TMDs

Na+ binding

Intracellular Phosphorlation Domain, TMD 6 & 7

Pharmacological Inhibitors of OCTN2 Quinidine

anti-malarial / antiarrhymic

Verapamil
Ca2+ flux inhibitor antiangina / antiarrhymic

Cephaloridine
b-lactam antibiotic

Competitive Inhibitors of OCTN2

O
CH3 CH2 CH3 CH2 N
+

CH2 CH3 CH2 CH3

CH3 CH2

CH2

CH

C O

CH3 CH2 CH2

TEA
Organic Cation (OC)

Valproate
Organic Anion (OA)

CH3 CH3 N
+

O CH2 CH OH CH2 C O
-

CH3

Carnitine
Zwitterion

J. Pharm. Exp. Ther., (2002), 302, 3, 1286

Binding Site Speculation Based on Competition Expts

OCTN2

J. Pharm. Exp. Ther., (2002), 302, 3, 1286

Cell (2003), 111, 113-122

Systemic Carnitine Deficiency

y Attributed to impaired hepatic biosynthesis and/or

excessive renal excretion of carnitine. y Plasma, liver, and muscle carnitine levels are reduced. y Usually manifests in infancy or childhood as progressive muscle weakness or episodes of hepatic and cerebral dysfunction precipitated by sustained exercise or fasting.

Systemic Carnitine Deficiency

y Symptoms include hypoglycemia, hyperammonemia,

and elevated levels of liver and muscle enzymes in serum y Cardiomyopathy and congestive heart failure are common and may be the direct cause of death. y Pathologically, the muscle shows marked increase in the number of lipid droplets, mainly in type I muscle fibers.

Myopathic Carnitine Deficiency

y Attributed to impairment in the active transportation

of carnitine from the plasma into muscle cells. y Normal carnitine biosynthesis but carnitine transport into the muscle is defective. y Carnitine level is reduced in muscles and is normal or slightly decreased in plasma and liver.

Myopathic Carnitine Deficiency

y Manifests during childhood or early adult life as

progressive proximal muscle weakness, exertional myalgias, cardiomyopathy y Muscle shows an increased number of lipid droplets, especially in type I muscle fibers.

Carnitine Deficiencies
Myopathic
Tissue Involved Carnitine Levels Plasma Carnitine Levels Serum Enzymes Fatty Infiltration Ketone Bodies Production Dysfunctions Carnitine Therapy Muscle Reduced only in muscle Normal Elevated in muscle Muscle Present Muscle Less responsive

Systemic
Several tissues and plasma Reduced in several tissues Normal/decreased Elevated in muscle and liver Muscle, liver, and other tissues Absent Hepatic, Central nervous system Responsive

Carnitine Transport System

Fatty Acid Oxidation in the Liver

Lipid Accumulation in Tissues

y Carnitine deficiency or abnormalities in carnitine

transferases blocks fatty acid oxidation y Acyl-CoA, without carnitine and carnitine transferases, will not be transported and oxidized in the mitochondria y Impaired fatty acid oxidation results to lipid accumulation in tissues such as the muscle and liver

FFA

ATP + CoA

AMP + PPi

AcylCoA
Carnitine palmitoyl transferase I

Acyl-CoA synthase

OUTER MITCHONDRIAL MEMBRANE CoA

AcylCoA
Caritine palmitoyl transferase II

Carnitine

Acylcarnitine
Carnitine acylcarnitin e translocase
Carnitine
Acyl-CoA

INNER MITCHONDRIAL MEMBRANE

CoA Acylcarnitine

FOxidation

Acylcarnitin e

Acyl CoA dehydrogenase

Enoyl CoA hydaratase

Acyl-CoA FAD FADH 2

Trans-EnoylCoA H2O

F-hydroxyacyl CoA NAD F-hydroxyl CoA NADH dehydrogen + H F-Ketoacyl ase CoA CoAKetothiolase SH Acyl-CoA + Acetyl-CoA

Citric Acid Cycle

Ketogene sis

FOxidatio Acetyl-CoA + n Acetyl-CoA

Thiolase

AcetylCoA

Citric Acid Cycle

Acetoacetyl HMG-CoA CoA AcetylSynthase CoA 3-Hydroxy-3methyl CoA HMG-CoA AcetylLyase CoA (exhaled thru Acetoacetic lungs) Acetone acid H2 F-hydroxybutyrate O FDH Hydroxybutyrate DH NADH + NAD H

pyruva te CO2 + ATP ADP + Pi Pyruvate carboxylase oxaloacet ate (+ ) Pyruvate DH Acetyl () CoA

Gluconeogen isis

Citric Acid Cycle

y Fatty acid alone cant penetrate into the inner

mitochondria membrane y The primary function of carnitine is to transfer longchain fatty acids from the cytosol into the mitochondria. y Acyl-CoA that enters the mitochondria undergoes beta oxidation which yields Acetyl-CoA as end product

` Thus the

inhibits the transport of Fatty acid into the mitochondria ` Ketone bodies are derived from Acetyl- CoA from oxidation of fatty acid in the liver. leads to the inhibition of pyruvate dehydrogenase, resulting in activation of Pyruvate carboxylase which catalyzes oxaloacetate(which is need in gluconeogenesis pathway)