Phenylketonurias: familial footing. Phenylketonuria ( PKU ) was first identified by the Norse doctor and biochemist Folling. He followed up his observation that piss of two retard siblings turned green on blending with an aqueous solution of ferrous chloride, by placing phenylpyruvic acid, and by observing the status in eight more idiot persons out of 430 whom he tested. He besides noted a inclination for these patients to hold a mousey smell, a just skin color, and dermatitis. Furthermore, he showed that overloading coneies with phenylalanine caused phenylpyruvic acid to look in their piss, and suggested that the upset was a familial defect of phenylalanine metamorphosis. This was confirmed by Jarvis ( 1947 ) , who showed that patients were unable to change over phenylalanine into tyrosine. The upset was named Phenylketonuria by Penrose ( 1935 ) .The name of the status derives from the urinary elimination of phenylpyruvic acid, a phenylketone.
Phenylketonuria ( PKU, MIM 261600 ) is the most common familial upset of amino acerb metamorphosis in European-descended populations. Phenylketonuria is transmitted by an autosomal recessionary manner of heritage ( typical Mendelian trait ) caused by mutants of the phenylalanine hydroxylase ( PAH ) cistron ( Scriver & A ; Kaufman. , 2001 ) .
The phenylalanine hydroxylase ( PAH ) , an enzyme that catalyzes the hydroxylation of the indispensable amino acid l-phenylalanine resulting in another amino acid, tyrosine, the rate-limiting measure in phenylalanine katabolism. This is the major tract for catabolizing dietetic l-phenylalanine and histories for about 75 % of the disposal of this amino acid. Lack in PAH consequences in hyperphenylalaninemia ( a plasma phenylalanine value of more than 120 AµM ) .If undiagnosed and untreated, PKUs can ensue in impaired postpartum cognitive development ensuing from a neurotoxic consequence of hyperphenylalaninemia ( Zurfluh et al. , 2008 ) .Since the debut of a dietetic intervention fifty old ages ago, PKU has been the paradigm for treatable familial disease and, subsequently for familial showing in human populations.Phenylketonuria is a “ multifactorial ” with familial ( familial ) and acquired ( dietetic ) constituents ( Knox. , ( 1972 ) as cited by Scriver & A ; Kaufman. , ( 2001 ) , both of which are necessary to set up the variant metabolic phenotype ( HPA ) .
The cistron for PAH was isolated in 1986, and later, a dramatic grade of allelomorphic heterogeneousness has been demonstrated in the PAH-deficient population ( Scriver et al.,1995 ) .The human PAH cistron covers 90 Kb of genomic DNA ( Konecki et al. , 1991 ) on chromsome12, band part q22-q24.1.It has 13 coding DNAs ( Konecki et al. , 1991 ) and a complex 5 ‘ untranslated part incorporating cis-acting, trans-activated regulative elements. The cistron is rich in intragenic polymorphous markers, including biallelic limitation fragment length polymorphism ( RFLP ) and individual nucleotide polymorphism ( SNP ) alleles, a tetranucleotide short tandem repetition ( STR ) moving as a fast molecular clock in noncoding DNA 3, and a variable figure of tandem repetitions ( VNTR,30-bp-long cassettes ) in the 3 ‘ untranslated part ( UTR ) .The polymorphous sites are in linkage disequilibrium and depict a big series of drawn-out and minihaplotypes.At the molecular degree, more than 500 disease associated allelomorphs of the PAH cistron have been identified in populations worldwide, about 90 % of them being point mutants among which merely a six history for the bulk of mutant chromosomes in Europeans and Orientals ; the balance are rare, even private, allelomorphs. Omissions in the cistron are non common.
Table 1. Class of mutants observed in the PAH Gene
Omissions ( chiefly little )
Percentage of mutants
Large omissions account for 2 % -3 % of mutants ( Kazak et al 2006 as cited by Scriver & A ; Mitchell ( 2007 )
Other PAH mutants delete little sums of Deoxyribonucleic acid from the cistron or interrupt the manner the cistron ‘s instructions are used to do phenylalanine hydroxylase. Although the huge bulk of mutants responsible for HPA map to the PAH venue, some occur at venue commanding the synthesis and recycling of tetrahydobiopterin ( BH4 ) , the indispensable cofactor for catalytic activity of phenylalanine enzyme. Each mutant induces a peculiar change in the enzyme ensuing in a corresponding quantitative consequence on residuary enzyme activity runing from complete absence to 50 % of normal values. Pattern of mutants show cultural fluctuation, a frequent cause among northern Europeans ( ~40 % ) is a G-to-A passage at the 5aˆ? giver splicing site in noncoding DNA 12, ensuing in absence of the C-terminus. Another common mutant is a C-to-T passage in exon 12, replaces the amino acerb arginine with the amino acid tryptophan at place 408 ( written as Arg408Trp or R408W ) . R408W histories for two-thirds of mutants in eastern Europe compared with 24 % in Scotland and a splicing mutant in noncoding DNA 10 histories for 40 % of Turkish mutations.PKU affects about 1 in 10,000 people in the UK and Europe and east Asian ( Scriver & A ; Kaufman ( 2001 ) , for Ireland it ‘s 1 in 4000 ( DiLella et al ( 1986 ) and Turkey, 1 in 3000 ( Ozalp et al ( 1986 ) , rare in afro-Caribbean ‘s, Indians and Ashkenazi Jews 1 in 200,000 ( Scriver & A ; Kaufman ( 2001 ) . The broad variableness in the common mutants between cultural groups and geographical countries make PAH lack a familial disease with great allelomorphic heterogeneousness. Approximately 98 % of PKU instances are caused by defects in the PAH cistron. The other 2 % are caused by defects in the biogenesis or reconversion of cofactor of PAH, 6 ( R ) -L-erythro-tetrahydrobiopterin ( BH4 ) . PAHdb, an on-line relational database was created in 1990s where mutant informations on the PAH cistron can be centralised ( hypertext transfer protocol: //www.pahdb.mcgill.ca/ ) .
The biochemical abnormalcy in PKU is an inability to change over phenylalanine into tyrosine. In normal kids, less than 50 % of dietetic consumption of phenylalanine is necessary for protein synthesis. The remainder is irreversible converted to tyrosine by PAH in the liver as portion of a complex tract ( figure 1 ) .
Phenylalanine hydroxylase requires as cofactors molecular O and decreased pteridine cofactor tetrahydrobiopterin ( BH4 ) , which Acts as an negatron bearer of this cofactor is dependent either on a regeneration from the quinonoid dihydrobiopterin by the enzyme dihydropteridine reductase ( DHPR ) or on de novo synthesis from quanosine triphosphate.Tyrosine, quinonoid dihydrobiopterin and H2O are the reaction merchandises. Intracellular tetrahydobiopterin is regenerated from quinonoid dihydrobiopterin, foremost by an of import tract tightly coupled with the hydroxylation reaction, catalysed by dihydropteridine reductase and using either NADH or NADPH as a H giver ; and secondly by tautomerization of quinonoid dihydrobiopterin, which is unstable, to the more stable 7,8- dihydrobiopterin, followed by decrease of the last named compound to tetrahydrobiopterin ( BH4 ) catalysed by dihydrofolate reductase with NADPH moving as H giver.
Figure 2: The phenylalanine hydroxylase ( PAH ) tract. Phenylketonuria normally is caused by a inborn lack of PAH ( reaction 1 ) , but it besides can ensue from defects in the metamorphosis of biopterin, which is a cofactor for the hydroxylase. Enzymes: 1, phenylalanine hydroxylase ; 2, dihydropteridine reductase ; 3, GTP cyclohydrolase ; 4, 6-pyruvoyltetrahydrobiopterin synthase. QH2, dihydrobiopterin ; BH4, tetrahydrobiopterin ; DEDT, d-erythro-dihydroneopterin triphosphate.
Several defects in different stairss in the metamorphosis of phenylalanine or its cofactors ( BH4 ) can ensue in elevated phenylalanine in tissues, plasma and piss. The lack of PAH raises plasma phenylalanine from its normal degree of 0.5 to 2.0 mg/dL to more than 20 mg/dL.
The accrued phenylalanine is transminated to phenylpyruvates, normal a minor tract of phenylalanine metamorphosis. The phenylypyruvate is converted to phenylacetate, phenyllactate and phenylacetylglutamine, which along with phenylalanine and phenylypyruvates is excreted in the piss ( figure 3 ) .
Figure 3 phenylalanine metamorphosis in PKU
The metabolic upsets associated with impaired ability to change over phenylalanine to tyrosine can be classified into three groups:
Defects in phenylalanine hydroxylase ( “ classical ” PKU less so 1 % activity of PAH ) .
Lack in dihydropteridine reductase ;
Disturbed de novo tetrahydrobiopterin biogenesis
This perturbation in metabolic homeostasis can hold clinical effect depending on its pathogenesis and its grade. The major associated clinical manifestation is impaired cognitive development and map ensuing from neurochemical instability: postnatally in affected instances and prenatally in the fetus of affected pregnant adult females.
Clinical presentation of Babies born with PKU
The clinical characteristics ( abnormalcies ) of PKU are absent at birth because phenylalanine and its metabolites are transferred across the placenta. Abnormalities develop within a few yearss if the neonate is untreated as serum phenylalanine and urinary phenylpyruvate rise ; they include the followers:
Lower birth weight so normal
No grounds of encephalon harm at birth ( unless born to fuss with PKU ) .
Vomiting, some times misdiagnosed as pyloric stricture.
Irritability, hapless eating
Seborrheic or eczematoid roseola ( mild and disappears as kid grows )
Unpleasant smell described as a musty or mousey odor of phenylacetic acid
Hypopigmentation ( just tegument and bluish eyes due to reduced melanin synthesis because of compromised tyrosine formation ) .
Most babies are hypertonic with overactive deep sinew physiological reactions
Epileptic tantrums, Seizures ( in approximately ~25 % -35 % )
Electroencephalographic abnormalcies ( 50 % ) .
Irreversible mental deceleration ( develops within 3-6 months following birth ) .
Excess phenylacetic acid in urine/perspiration.
Peculiarities of pace, stance, and sitting position.
Behaviour jobs ; autistic-like behaviors, hyperactivity, agitation, aggression ( seen in untreated grownups ) .
In untreated kids outstanding upper jaw with widely spaced dentitions, enamel hypoplasia, and growing deceleration are other common determination. The incidence and badness epilepsy is closely related to the grade of rational damage and is non specific for this status. Adults with PKU whose status were non detected ( pre PKU neonatal showing in developed universe ) , these patients have impaired intelligence and lose ~50 points off their IQ during the first 12 months ( Koch et al.1974 ) as cited by ( Scriver & A ; Kaufman.2001 ) and frequently have just tegument and bluish eyes, this can be attributed to cut down melanin synthesis because of suppression of tyrosinase activity by phenylalanine accretion. The most badly affected grownups are microcephalie holding a skull perimeter of less than 43 centimeter. Although an baby with untreated PKU is normal at birth, defects in myelination and gliosis with lacking nervus cell ripening occur quickly if a normal diet is given in first few months. If a phenylalanine-free diet is instituted, farther rational and neurological impairment are prevented but if any impairment has already occurred, there is small recovery to the position quo ante.
The mechanism by which high phe concentration consequences in rational damage is yet to be clarified, harmonizing to Scriver & A ; Kaufman ( 2001 ) PKU pathogenesis can be considered from three position points ;
Lack of tyrosine in the encephalon
The consequence of phenylalanine on conveyance and distribution of metabolities in the encephalon
An consequence on neurochemical procedures.
PKU is a disease of unnatural degrees of normal aminic acid ; tyrosine is promoted to the position of an indispensable dietary amino acid in PKU because of sever lack of the hepatic enzyme phenylalanine hydroxylase. Tyrosine is a precursor of tetraiodothyronine, melanin and the neurotransmitter Dopastat and norepinephrine and is incorporated in all proteins. Tyr is converted to l-DOPA ( 3, 4-dihydroxy-l-Phe ) , a precursor of Dopastat and other catecholamine neurochemicals ; in the “ tyrosine/dopamine ” theory ( I ) the foetus/newborn is unable to obtain tyrosine from phe supply due to the inactive PAH, ( two ) the maternal supply of tyrosine is besides compromised in bearers of PKU ( heterozygosity ) .this hypothesis is non supported by the undermentioned grounds ; ( 1 ) postnatal tyrosine addendum without decrease of phe entirely does non forestall impaired postpartum cognitive development, ( 2 ) phe limitation entirely should non be good, harmonizing to hypothesis but yet it does prevent neurotoxicity ( intervention of PKU ) .
The consequence of phenylalanine on conveyance and distribution of metabolites in the encephalon ;
Large impersonal amino acids ( LNAAs ) including phe, compete for conveyance across the blood encephalon barrier ( BBB ) via the L-type amino acid bearer. Elevated plasma phe impairs encephalon consumption of other LNAAs in patients with PKU. Amino acerb consumption on system L across the BBB can be measured noninvasively in vivo by antielectron emanation imaging utilizing a labeled [ 11C ] inert substrate.in vivo surveies show competition between big impersonal amino acids, such as branched concatenation amino acids, tyrosine and tryptophan and phe on the blood encephalon barrier conveyance system. Phenylalanine has the highest affinity for the system. Consequently elevated concentration of phe could impair uptake of bifurcate concatenation amino acids ( tyrosine and tryptophan ) cut downing there handiness for synthesis of neurotransmitters ( intellectual Dopastat and serotonin depletion ) in the encephalon in hyperphenylalaninemic province in PKU. Direct effects of elevated Phe concentrations on several enzyme systems, and effects of a attendant depletion of other LNAAs in the encephalon, are thought to be the most of import factors for the disturbed encephalon development in untreated PKU ( Pietz et al. , 1999 ) .
An consequence on neurochemical procedures.
The neuropathology seen in treated and untreated PKU appears to affect hypomyelination and demyelination or both. Brain histology and cellular development are altered in human PKU. The figure and spread of dendritic basilar procedures of big pyramidic cells are reduced by HPA in rat whelps, high degrees of phe and its metabolites, both in civilization and in vivo lessening proliferation and increase loss of nerve cells. Deoxyribonucleic acid content is decreased in affected encephalon cells, and its synthesis is impaired. The net consequence is impaired encephalon growing. Long exposure to the aberrant metabolic phenotype impairs development of encephalon architecture in untreated PKU patients, with abnormalcies in myelination, breadth of cortical home base, cell denseness and administration, dendritic arborization, and figure of synaptic spinal columns. Phenylalanine itself is likely the neurotoxic agent in PKU. Metabolites of phenylalanine are non found in the human ( or mouse ) disease at sufficiently high concentration to administer metabolic and chemical relationships in encephalon.
Diagnosis and Laboratory proving /screening
All babies in the UK are screened for PKU at 6-14 yearss old, after set uping eating and protein consumption. The trial is non done earlier 3 to 4 yearss of age because Babies with PKU often display normal blood phe at birth. The female parent is able to clear extra phe in her affected fetus through the placenta. Phenylalanine degree in PKU additions in relation to clip after birth in the first hebdomad of life. The diagnosing of classical PKU normally depends on presentation of relentless lift of plasma phenylalanine concentrations. The concentration of phe must be at least 5 A- the upper bound of normal ( 0.5 to 2.0 mg/dL ) before it is associated with deceleration.Prior to the newborn showing programmes in the UK for PKU in the 1960 ; PKU was one of the common causes of mental deceleration. Collection of newborn blood by heel asshole onto filter paper cards has become an recognized aspect of newborn attention through out the developed universe. Biochemical designation of PKU original was by a color alteration reaction of urinary phenylpyruvic acid with ferrous chloride. This resulted in excessively many false negatives and was replaced in UK in the 1960 by Guthrie bacterial suppression check. Guthrie trial involves finding the ability of plasma to back up growing of the bacteria Bacillus subtilis, which can merely turn if phenylalanine is present in medium. The bacterial suppression check is being replaced by chromatographic, fluorometric or mass spectrometric methods for the appraisal of phenylalanine. Fluorometric and HPLC techniques provide high degrees of truth. Patients with negative Guthrie trial are recommended for HPLC and fluorometric for the sensing of heterozygous and for finding the extent of hyperphenylalaninaemia in maternal PKU. Absence of dihydropteridine reductase ( DHPR ) activity consequences in lacking phenylalanine in the presence of normal phenylalanine hydroxylase enzyme and besides in lacking neurotransmitter production. Defects in the synthesis of biopterin, which produce the same effects as DHPR lack, are identified by urine check of biopterin and neopterin.
Molecular Diagnosis of PKU
PKU mutant analysis is of import in sensing of bearers, for antenatal diagnosing. Polymorphous haplotypes can be analysed at the PAH venue. Molecular genetic sciences techniques utilized include Southern blotting, limitation enzyme digestion, sensing of mutant by sequencing and manifold ligation investigation elaboration.
Table 2 Probe of neonatal hyperphenylalaninemia
Quantitative analysis of plasma amino acids
To find accurately the plasma phe concentration and the concentration of tyrosine in order to separate hyperphenylalaninemia caused by transeunt familial defects in tyrosine metamorphosis
Blood DHPR assay
For the diagnosing of DHPR lack. This can be on dried blood musca volitanss.
Urinary biopterin/neopterin ratio and per centum BH4
To place defects in biopterin biogenesis. Must be done before BH4 lading trial.
BH4 lading trial
Another attack to the designation of defects in BH4 biogenesis. Consecutive measurings of plasma phenylalanine are done instantly before an at 4-hour interval after unwritten disposal of BH4, 20 milligram per Kg organic structure weight
PAH mutant analysis
Rarely needed for diagnosing of PKU. However, it is necessary for antenatal diagnosing of the status in future gestations.
Autosomal individual cistron heritage
Single cistron defects ( besides known as Mendelian upsets, monogenic upsets or individual venue upsets. these are a group of diseased caused by a individual mutated cistron which alters the coding information and produces a protein which is either faulty or no protein at all. The disease symptoms are a direct consequence of the protein lack in map ( structural ) or absence. Three form of heritage occur:
Autosomal recessive-inborn mistakes of metamorphosis
Inherited metabolic disease are inherited in the same mode as Garrod ‘s original congenital mistakes of metamorphosis, they are Mendelian, individual cistron defects, transmitted in an autosomal recessionary mode. The somatic chromosomes ( 44 ) comprise 22 homologus braces of chromosomes ; within the chromosome the cistron occupy a specific location or venue. The somatic chromosomes are inherited in braces one from maternal and one from paternal. The single must be homozygous for the mutant in same cistron for disease look. The parents who are heterozygous for mutation ( allelomorph ) cistron are bearers and pass the mutant to there offspring.Expression of mutant cistron ( metabolic defect ) might non be seen in several coevals, autosomal recessionary individual cistron disease frequently show clear form in which the disease “ skips ” one or more coevalss.
There is a 25 % ( homozygote ‘s ) chance of holding affected child e.g. with cystic fibrosis, and 50 % ( heterozygote ‘s ) of offspring to be bearers and 25 % that the progeny will non recessive the faulty cistron and will non be a bearer. If one parent is bearer and the other is normal there is a 50 % opportunity will non recessive the faulty cistron and 50 % opportunity that there off spring will be a bearer, there ‘s a 0 % opportunity that there kid will hold the disease.
Figure 1: Autosomal recessionary heritage
There are more than 6600 human individual cistron upsets, which jointly affect ~2 % of population. The most common autosomal recessionary individual cistron upset amongst Caucasians is cystic fibrosis, which occurs in a frequence of 1 in 25oo.The a?†F508 mutant is the most common and consequences in a faulty cystic fibrosis transmembrane conductance regulator ( CFTR ) .
Autosomal Recessive Disorders
With autosomal recessionary heritage, the heterozygous bearers of a individual mutant normally are clinically normal ; seldom, they may demo some clinical marks ( attesting heterozygote ‘s ) . However, individuals who have inherited a mutant in the same cistron from both parents ( homozygote ‘s ) will demo clinical manifestations of the disease. If both parents are bearers of a mutant in the same cistron, so each of their kids has a 25 % hazard for being homozygous for that cistron and holding the disease. Autosomal recessionary upsets normally are seen in merely one coevals, typically among siblings ( Fig. 43-3 ; see Table 43-1 ) . Both males and females can be affected. In little households, autosomal recessionary upsets may look as stray or sporadic instances. Autosomal recessionary upsets may sometimes look in multiple coevalss of extremely inbred households with akin matrimonies. Examples of autosomal recessionary neurological upsets are PKUs ( PKU ) , Tay-Sachs disease, Lafora organic structure myoclonic epilepsy, childish spinal muscular wasting, Wilson ‘s disease, and Friedreich ‘s ataxy.
Analysiss of diploid PAH genotypes and their correlativities with
metabolic and clinical phenotypes show that some mutants
( normally null allelomorphs ) confer the classical PKU phenotype, whereas
others ( normally missense allelomorphs ) confer signifiers of HPA in a
quasicontinuous genotype-phenotype distribution reflecting ”phenogenetic
equality ” [ Weiss and Buchanan, 2003 ] . But within
the latter, phenotypes are non ever consistent with anticipations
from genotype [ Kayaalp et al. , 1997 ; Guldberg et al. , 1998 ; Desviat
et al. , 1999 ] . Furthermore, patients with similar mutation genotypes
can hold dissimilar phenotypes.
A individual procedure can non by it self explain the PKU encephalon phenotype, a multiple of complex inter linking biochemical tracts and conveyance of metabolities ( across the blood -brain barrier ) defects, finally consequence in distribution of normal chemical homeostasis of the encephalon and consequence in impaired encephalon development