Chapter 6 · The Glycogen Storage Diseases and Related Disorders102 II Glycogen Metabolism Glycogen is a macromolecule composed of glucose units. It is found in all tissues but is most abundant in liver and muscle where it serves as an energy store, pro- viding glucose and glycolytic intermediates ( . Fig. 6.1). Numerous enzymes intervene in the synthesis and deg- radation of glycogen which is regulated by hormones. . Fig. 6.1. Scheme of glycogen metabolism and glycolysis. PGK, phosphoglycerate kinase; P, phosphate; PLD, phosphorylase limit dextrin; UDPG, uridine diphosphate glucose. Roman numerals indicate enzymes whose deficiencies cause liver (italics) and/or muscle glycogenoses: 0 glycogen synthase, I, glucose-6-phos- phatase; II, acid maltase (D-glucosidase); III, debranching enzyme; IV, branching enzyme; V, myophosphorylase; VI, liver phosphory- lase; VII, phosphofructokinase; IX, phosphorylase-b-kinase; X, phosphoglycerate mutase; XI, lactate dehydrogenase; XII, fruc- tose-1,6-bisphosphate aldolase A; XIII, E-enolase 6 103 The liver glycogen storage disorders (GSDs) comprise GSD I, the hepatic presentations of GSD III, GSD IV, GSD VI, the liver forms of GSD IX, and GSD 0. GSD I, III, VI, and IX present similarly with hypoglycemia, marked hepato- megaly, and growth retardation. GSD I is the most severe affecting both glycogen breakdown and gluco- neogenesis. In GSD Ib there is additionally a disorder of neutrophil function. Most patients with GSD III have a syndrome that includes hepatopathy, myopathy, and often cardiomyo pathy. GSD VI and GSD IX are the least severe: there is only a mild tendency to fasting hypo- glycemia, liver size normalises with age, and patients reach normal adult height. GSD IV manifests in most patients in infancy or childhood as hepatic failure with cirrhosis leading to end-stage liver disease. GSD 0 presents in infancy or early childhood with fasting hypoglycemia and ketosis and, in contrast, with post- prandial hyperglycemia and hyperlactatemia. Treat- ment is primarily dietary and aims to prevent hypoglyc- emia and suppress secondary metabolic decompensa- tion. This usually requires frequent feeds by day, and in GSD I and in some patients with GSD III, continuous nocturnal gastric feeding. The muscle glycogenoses fall into two clinical groups. The first comprises GSD V, GSD VII, the muscle forms of GSD IX (VIII according to McKusick), phospho- glycerate kinase deficiency (IX according to McKusick), GSD X, GSD XI, GSD XII and GSD XIII, and is character- ised by exercise intolerance with exercise-induced myalgia and cramps, which are often followed by rhab- domyolysis and myoglobinuria; all symptoms are reversible with rest. Disorders in the second group, consisting of the myopathic form of GSD III, and rare neuromuscular forms of GSD IV, manifest as sub-acute or chronic myopathies, with weakness of trunk, limb, and respiratory muscles. Involvement of other organs (erythrocytes, central or peripheral nervous system, heart, liver) is possible, as most of these enzymes de- fects are not confined to skeletal muscle. Generalized glycogenoses comprise GSD II, caused by the deficiency of a lysosomal enzyme, and Danon disease due to the deficiency of a lysosomal membrane protein. Recent work on myoclonus epilepsy with Lafora bodies ( Lafora disease) suggests that this is a glycogenosis, probably due to abnormal glycogen synthesis. GSD II can be treated by enzyme replace- ment therapy, but there is no specific treatment for Danon and Lafora disease. The glycogen storage diseases (GSDs) and related disorders are caused by defects of glycogen degradation, glycolysis and, paradoxically, glycogen synthesis. They are all called glycogenoses, although not all affect glycogen breakdown. Glycogen, an important energy source, is found in most tissues, but is especially abundant in liver and muscle. In the liver, glycogen serves as a glucose reserve for the main- tenance of normoglycemia. In muscle, glycogen provides energy for muscle contraction. Despite some overlap, the GSDs can be divi ded in three main groups: those affecting liver, those affecting muscle, and those which are generalized ( . Table 6.1). GSDs are d enoted by a Roman numeral that reflects the historical sequence of their discovery, by the deficient enzyme, or by the name of the author of the first description. The Fanconi- Bickel syndrome is discussed in Chap. 11. 6.1 The Liver Glycogenoses The liver GSDs comprise GSD I, the hepatic presentations of GSD III, GSD IV, GSD VI, the liver forms of GSD IX, and GSD 0. GSD I, III, VI, and IX present with similar symp- toms d uring infancy, with hypoglycemia, marked hepatome- galy, and retarded growth. GSD I is the most severe of these four conditions because not only is glycogen breakdown impaired, but also gluconeogenesis. Most patients with GSD III have a syndrome that includes hepatopathy, myo- pathy, and often cardiomyopathy. GSD IV manifests in most patients in infancy or childhood as hepatic failure with cirrhosis leading to end-stage liver disease. GSD VI and the hepatic forms of GSD IX are the mildest forms: there is only a mild tendency to fasting hypoglycemia, liver size normalises with age, and patients reach normal adult height. GSD 0 presents in infancy or early childhood with fasting hypoglycemia and ketosis contrasting with postprandial hyperglycemia and hyperlactatemia. The muscle forms of GSD III and IX are also discussed in this section. 6.1.1 Glycogen Storage Disease Type I (Glucose-6-Phosphatase of Translo- case Deficiency) GSD I, first described by von Gierke, comprises GSD Ia caused by deficiency of the catalytic subunit of glucose-6- phosphatase (G6Pase), and GSD Ib, due to deficiency of the endoplasmic reticulum (ER) glucose-6-phosphate (G6P) translocase. There is controversy about the existence of ER phosphate translocase deficiency (GSD Ic) and ER glucose transporter deficiency (GSD Id) as distinct entities. In this chapter, the term GSD Ib includes all GSD I non-a forms. Clinical Presentation A protruded abdomen, truncal obesity, rounded doll face, hypotrophic muscles, and growth delay are conspicuous clinical findings. Profound hypoglycemia and lactic acidosis occur readily and can be elicited by trivial events, such as delayed meals or reduced food intake associated with inter- 6.1 · The Liver Glycogenoses Chapter 6 · The Glycogen Storage Diseases and Related Disorders104 II current illnesses. The liver functions are normal and cir- rhosis does not develop. In the second or third decade, the liver’s surface may become uneven and its consistency much firmer because of the development of adenomas. The kid- neys are moderately enlarged. The spleen remains normal in GSD Ia but is enlarged in most patients with GSD Ib. Patients bruise easily due to impaired platelet function, and nosebleeds may be especially troublesome. Skin xanthomas are seen in patients with severe hypertriglyceridemia, and gouty arthritis in patients with hyperuricemia. Patients may also suffer from episodes of diarrhoea or loose stools. About one in five GSD I patients has type Ib [1]. Most patients with GSD Ib develop neutropenia before the age of 1 year, a few at an older age, and even fewer are totally . Table 6.1. Main features of glycogen storage diseases and related disorders Type or synonym Defective enzyme or transporter Main tissue involved Main clinical symptoms Liver Ia Von Gierke Glucose-6-phosphatase Liver, kidney Hepatomegaly, short stature, hypoglycemia, lactatemia, hyperlipidemia Ib (non-a) Glucose-6-phosphate translocase Liver, kidney, leucocytes Same as Ia, neutropenia, infections III Cori, Forbes Debranching enzyme and sub- types Liver, muscle Hepatomegaly, (cardio)myopathy, short stature, hypo- glycemia IV Andersen Branching enzyme Liver Hepato(spleno)megaly, liver cirrhosis, rare neuromuscu- lar forms VI Hers Liver phosphorylase Liver Hepatomegaly, short stature, hypoglycemia IX Phosphorylase kinase and subtypes Liver and/or muscle Hepatomegaly, short stature (myopathy), hypoglycemia 0G lycogen synthase Liver Hypoglycemia Muscle V Mc Ardle Myophosphorylase MuscleMyalgia, exercise intolerance, weakness VII Tarui Phosphofructokinase and variants Muscle, erythrocytes Myopathy, hemolytic anemia, multisystem involvement (seizures, cardiopathy) – Phosphoglycerate kinase Muscle, erythrocytes, central nervous system Exercise intolerance, hemolytic anemia convulsions X Phosphoglycerate mutase Muscle Exercise intolerance, cramps XI Lactate dehydrogenase Muscle Exercise intolerance, cramps, skin lesions XII Aldolase A Muscle Exercise intolerance, cramps XIII E-Enolase Muscle Exercise intolerance, cramps Generalized II Pompe Lysosomal D-glucosidase Generalized in lysosomes Hypotonia, cardio-myopathy Infantile, juvenile, adult forms IIb Pseudo Pompe Danon Lysosomal-associated membrane protein 2 Heart, muscle Cardio-myopathy Lafora Enzyme defect not known Polyglucosan bodies in all organs Myoclonic epilepsy, dementia, convulsions 6 105 spared. Patients with neutropenia show neutrophil dys- function, including impaired motility and migration and impaired metabolic burst [2], and suffer with frequent and severe infections, which can affect the upper and lower respiratory tract, the skin, the urinary tract, or result in deep abscesses [3]. More than 75% of the GSD Ib patients show symptoms of inflammatory bowel disease (IBD), including peri-oral and peri-anal infections and protracted diar- rhoea. Metabolic Derangement Among the enzymes involved in hepatic glycogen metabo- lism, G6Pase is unique since its catalytic site is situated inside the lumen of the ER. This means that its substrate, G6P, must cross the ER membrane and requires a trans- porter. There is still debate over different proposed models of G6Pase, over the existence of additional transporters for its products, phosphate and glucose [4, 5], and over the existence of GSD Ic (putative ER phosphate/pyrophosphate transporter deficiency), and GSD Id (putative ER glucose transporter deficiency). In particular, patients diagnosed by enzyme studies as GSD Ic have been found to have the same mutations in the G6P translocase gene as in GSD Ib (see Genetics) [6]. The description of a GSD Id patient has been withdrawn [7], and no other patient with GSD Ic has been reported [8]. Hypoglycemia occurs during fasting as soon as exoge- nous sources of glucose are exhausted, since the final steps in both glycogenolysis and gluconeogenesis are blocked. However, there is evidence that GSD I patients are capable of some endogenous hepatic glucose production [9], al- though the mechanism is still unclear. Residual G6Pase activity or the activity of non specific phosphatases may result in hydrolysis of G6P to glucose; glycogen may be de- graded into glucose by amylo-1,6-glucosidase, or autophagy combined with lysosomal acid maltase activity. Hyperlactatemia is a consequence of excess G6P that cannot be hydrolysed to glucose and is further metabolised in the glycolytic pathway, ultimately generating pyruvate and lactate. This process is intensified under hormonal stimulation as soon as the exogenous provision of glucose fails. Substrates such as galactose, fructose and glycerol need liver G6Pase to be metabolised to glucose. Conse- quently ingestion of sucrose and lactose results in hyperlac- tatemia, with only a small rise in blood glucose [10]. The serum of untreated patients has a milky appearance due to hyperlipidemia, primarily from increased triglycer- ides with cholesterol and phospholipids less elevated. The hyperlipidemia only partially responds to intensive dietary treatment [11, 12]. The increased concentrations of trigly- cerides and cholesterol are reflected in increased numbers of VLDL and LDL particles, whereas the HDL particles are decreased [13]. VLDL particles are also increased in size due to the accumulation of triglycerides. Hyperlipidemia is a result of both increased synthesis from excess of acetyl- coenzyme A (CoA) via malonyl-CoA, and decreased serum lipid clearance [14]. Elevated hepatic G6P levels may also play a role via activation of transcription of lipogenic genes. Decreased plasma clearance is a result of impaired uptake and impaired lipolysis of circulating lipoproteins. Reduced ketone production during fasting is a consequence of the increased malonyl-CoA levels, which inhibit mitochon- drial E-oxidation [15]. Hyperuricemia is a result of both increased production and decreased renal clearance. Increased production is caused by increased degradation of adenine nucleotides to uric acid, associated with d ecreased intra-hepatic phos- phate concentration and ATP depletion [16]. Decreased renal clearance is caused by competitive inhibition of uric acid excretion by lactate [17]. Genetics Both GSD Ia and Ib are autosomal recessive disorders. In 1993, the gene encoding G6Pase (G6PC) was identified on chromosome 17q21. Today more than 75 different muta- tions have been reported [18, 19]. Subsequently, the gene encoding the G6P transporter (G6PT) was identified on chromosome 11q23. More than 65 different mutations have been reported [20]. Patients formerly diagnosed by enzyme studies as GSD Ib, Ic and the putative Id shared the same mutations in G6PT [6]. Recently however, a GSD Ic patient without mutations in G 6PT was described suggesting the existence of a distinct GSD Ic locus [21]. Diagnosis GSD Ia is characterized by deficient G6Pase activity in intact and disrupted liver microsomes, whereas deficient G6Pase activity in intact microsomes, and (sub)normal G6Pase activity in disrupted microsomes, indicates a defect in the G6P transporter [22]. However, enzyme studies in liver tissue obtained by biopsy are now usually un-necessary since the diagnosis can be based on clinical and biochemical find- ings combined with DNA investigations in leukocytes. If patients suffer from neutropenia, recurrent infections and/ or IBD, mutation analyses of G6PT should be performed first [18, 19], although in younger GSD Ib patients these findings are not always present [3]. If no mutations in G6PC or in G6PT are identified, a glucose tolerance test should be performed. A marked decrease in blood lactate concentra- tion from an elevated level at zero time indicates a gluconeo- genesis disorder, including GSD I, whereas an increase in blood lactate concentration suggests one of the other hepatic GSDs. If the suspicion of GSD I remains, enzyme assays in fresh liver tissue should be performed. Identification of mutations in either G6PC or G6PT alleles of a GSD I index case allows reliable prenatal DNA- based diagnosis in chorionic villus samples. Carrier detec- tion in the partners of individuals carrying a known muta- tion is a reliable option, since a high detection rate is ob- served for both G6PC and G6PT. 6.1 · The Liver Glycogenoses Chapter 6 · The Glycogen Storage Diseases and Related Disorders106 II Treatment Dietary Treatment The goal of treatment is, as far as possible, to prevent hypoglycemia, thus limiting secondary metabolic derange- ments. Initially, treatment consisted of frequent carbo- hydrate-enriched meals during day and night. In 1974, continuous nocturnal gastric drip feeding (CNGDF) via a nasogastric tube was introduce d, allowing both patients and parents to sleep during the night [23]. CNGDF can be used in very young infants. Both a glu- cose/glucose polymer solution and a formula (sucrose and lactose-free/low in GSD I) enriched with maltodextrin are suitable. There are no studies comparing these two metho ds. CNGDF should be started within 1 h after the last meal. Otherwise, a small oral or bolus feed should be given. Within 15 min after the discontinuation of the CNGDF, a feed should be given. CNGDF can be given using a naso gastric tube or by gastrostomy. Gastrostomy is con- traindicated in GSD Ib patients because of the risk of IBD and local infections. It is advisable to use a feeding pump that accurately controls flow rate and has alarms alerting of flaws in the system. Parents need thorough teaching with meticulous explanation of technical and medical details and should feel completely confident with the feeding pump system. In 1984 uncooked cornstarch (UCCS), from which glucose is more slowly released than from cooked starch, was introduced [24]. During the day, this prolongs the period between meals, thus improving metabolic control. Overnight, it may be used as an alternative for CNGDF. Theoretically, pancreatic amylase activity is insufficiently mature in children less than 1 year of age and therefore UCCS should not be started in these patients. Nevertheless, it may be effective and useful even in these younger children [25]. The starting dose of 0.25 g/kg bodyweight should be increased slowly to prevent side-effects, such as bowel dis- tension, flatulence, and loose stools, although these side- effects are usually transient. Precaution is needed in GSD Ib patients since UCCS may exaggerate IBD. UCCS can be mixed in water in a starch/water ratio of 1:2. If UCCS is used overnight, no glucose should be added to avoid insulin re- lease and an UCCS tolerance test should be performed to investigate the permissible duration of the fasting period. It has been documented that both CNGDF and UCCS can maintain normoglycemia during the night with equally favourable (short-term) results [26, 27]. UCCS is also used in daytime to prolong the fasting period. Glucose requirements decrease with age and are calcu- lated from the theoretical glucose production rate, which va- ries between 8–9 mg/kg/min in neonates and 2–3 mg/kg/min in adults. Only the required amount of glucose should be given since larger quantities of exogenous glucose may cause undesired swings in glycemia which make patients more sen- sitive to rebound hypoglycemia and increases peripheral body fat storage. During infections, a freq uent supply of exogenous glu- cose must be maintained, even though anorexia, vomiting, and diarrhoea may make this difficult. Furthermore, glu- cose metabolism is increased with fever. Replacement of meals and snacks by glucose polymer drinks is often need- ed. Nasogastric drip feeding 24 h a day may be necessary. If this is not tolerated, a hospital admission is indicated for intravenous therapy. There is no consensus as to the extent to which lactate production from galactose and fructose should be avoided. Lactate may serve as an alternate fuel for the brain, thereby protecting patients against cerebral symptoms from re- duced glucose levels [28]. Furthermore, milk products, fruits and vegetables are important sources of vitamins and minerals. On the other hand, stringent maintenance of normolactatemia by complete avoidance of lactose and fructose ingestion may lead to a more favourable out- come [29]. The dietary plan should be carefully designed and fol- lowed to provide enough essential nutrients as recommend- ed by the WHO. Otherwise, supplementation should be started. Special attention should be directed to calcium (limited milk intake) and vitamin D. Furthermore, increas- ed carbohydrate metabolism needs an adequate supply of vitamin B 1 . Prior to elective surgery, bleeding time (platelet aggrega- tion) should be normalised by continuous gastric drip feeding for several days or by intravenous glucose infusion over 24–48 hours. Close peri-operative monitoring of blood glucose and lactate concentration is essential. Pharmacological Treatment Until recently, (sodium)bicarbonate was recommended to reduce hyperlactatemia. Bicarbonate also induces alkalisa- tion of the urine, thereby diminishing the risk of urolithiasis and nephrocalcinosis. However, it was found that a progres- sive worsening of hypocitraturia occurs [30] so that alkali- sation with citrate may be even more beneficial in prevent- ing or ameliorating urolithiasis and nephrocalcinosis. Uric acid is a potent radical scavenger and it may be a protective factor against the development of atherosclerosis [31]. Consequently, it is recommended to accept a serum uric acid concentration within the high normal range. To prevent gout and urate nephropathy, however, a xanthine-oxidase inhibitor (allopurinol) should be started if it exceeds this. If persistent microalbuminuria is present, a (long-act- ing) angiotensin converting enzyme (ACE) inhibitor should be started to reduce or prevent further deterioration of renal function. Addi tiona l blood pressure lowering drugs should be used if blood pressure remains above the 95th percentile for age. To reduce the risk of cholelithiasis and pancreatitis, tri- glyceride-lowering drugs (nicotinic acid, fibrates) are indi- cated only if severe hypertriglyceridemia persists. Choles- terol-lowering drugs are not indicated in younger patients. 6 107 In adult patients however, progressive renal insufficiency may worsen the hyperlipidemia and atherogenecity, and in such cases statins may be indicated, although there is at present no evidence of their efficacy. Fish-oil is not indicated since its effect on reducing serum triglycerid e and cholesterol is not long lasting and it may even lead to increased lipoprotein oxidation, thereby increasing atherogenecity [32]. There is no place for growth hormone the r apy since, although it may enhance growth, it does not improve final height. Similarly, neither are oest rogen and testosterone in- dicated to enhance pubertal development as they do not improve final height scores. Ethinyloestradiol should be avoided both because of its association with liver adenomas and its incompatibility with hyperlipidemia. Oral contr acep- tion is possible with high doses of progestagen from the 5th to the 25th day of the cycle or with daily administration of low doses of progestagen [33]. The benefits of prophylaxis with oral antibiotics have not been studied in neutropenic GSD Ib patients. However, prophylaxis with cotrimoxazol may be of benefit in sympto- matic patients or in those with a neutrophil count < 500 u 10 6 /l [34]. Although patients with GSD Ib and neutropenia have been treated with granulocyte colony-stimulating factor (GCSF) from 1989 and it is widely thought that the severity of infections decreases and IBD regresses, no unequivocal improvement in outcome has been established [35]. It is advised to limit the use of GCSF to one or more of the fol- lowing indications: (1) a persistent neutrophil count below 200 u 10 6 /1; (2) a single life threatening infection requiring antibiotics intravenously; (3) serious IBD documented by abnormal colonoscopy and through biopsies; or (4) severe diarrhoea requiring hospitalisation or disrupting normal life [36]. Patients generally respond to low doses (starting dose 2.5 µg/kg every other day). Data on the safety and efficacy of long-term GCSF administration are limited. The most serious frequent complication is splenomegaly includ- ing hypersplenism. Reports of acute myelogenous leukemia [37] and renal carcinoma [38] arising during long-term use of GCSF make stringent follow-up necessary. Bone marrow aspiration with cytogenetic studies before treatment and once yearly during GCSF treatment are advised, along with twice yearly abdominal ultrasound. Follow-up, Complications, Prognosis, Pregnancy The biomedical targets are summarised in . Table 6.2 and are based on what level of abnormality constitutes an added health risk [39]. One should attempt to approach these targets as far as possible, but without reducing the quality of life. A single blood glucose assay in the clinical setting is not useful; it is preferable to make serial glucose measurements at home preprandially and in the night over 48–72 h. Lactate excretion in urine should be estimated in samples collected at home and delivered frozen [40, 41]. Serum uric acid, cholesterol and triglyceride concentrations, and venous blood gases should be estimated during each outpatient visit. A good marker for the degree of apparent asymptomatic IBD activity in GSD Ib is faecal alpha-1-antitrypsine [42]. Intensive dietary treatment with improved metabolic and endocrine control has led to reduced morbidity and mortality, and improved quality of life [29]. Long-term cerebral function is normal if hypoglycemic damage is pre- vented. Most patients are able to lead fairly normal lives. With ageing, however, patients may develop complications of different organ systems [1, 25, 43]. Proximal and distal renal tubular as well as glomerular functions are at risk [44, 45]. Proximal renal tubular dys- function is observed in patients with poor metabolic con- trol and improves after starting intensive dietary treatment [46]. However, distal renal tubular dysfunction can occur even in patients with optimal metabolic control and may lead to hypercalciuria and hypocitraturia [47, 48]. Regular ultrasonography of the kidneys is recommended. Progres- sive glomerular renal disease starts with a silent period of hyperfiltration that begins in the first years of life [49]. Microalbuminuria may develop at the end of the first or in the second decade of life and is an early manifestation of the progression of renal disease [50]. Subsequently, proteinuria and hypertension may develop, with deterioration of renal function leading to end-stage renal disease in the 3rd–5th decade of life. The similarities in the natural history of renal disease in GSD I and of nephropathy in insulin dependent diabetes mellitus is striking. The pathogenesis however, is still unclear. As in diabetic nephropathy, ACE inhibitors should be started if microalbuminuria persists over a period of 3 months with a moderate dietary restriction of protein and sodium. Hemodialysis, continuous ambulatory peri- toneal dialysis and renal transplantation are therapeutic options for end-stage renal disease in GSD I. Single or multiple liver adenomas may develop in the second or third decade [51, 52] but remain unchanged . Table 6.2. Biomedical targets in GSD I 1. Preprandial blood glucose >3.5–4.0 mmol/l (adjusted to target 2) 2. Urine lactate/creatinine ratio <0.06 mmol/mmol (or urine lactate <0.4–0.6 mmol/l) 3. Serum uric acid concentration in high normal range for age and laboratory 4. Venous blood base excess >–5 mmol/l and venous blood bicarbonate >20 mmol/l 5. Serum triglyceride concentration <6.0 (<10.0 mmol/l in adult patients) 6. Normal faecal alpha-1-antitrypsine for GSD Ib patients 7. Body mass index <+2.0 SDS (in growing children between 0 and +2.0 SDS) 6.1 · The Liver Glycogenoses Chapter 6 · The Glycogen Storage Diseases and Related Disorders108 II during many years of intensive dietary treatment; a reduc- tion in size and/or number has been observed in some pa- tients following optimal metabolic control. Liver adenomas may cause mechanical problems and acute haemorrhage; further more, they may develop into carcinomas. To screen for adenomas and to follow their size and number, ultra- sonography should be performed regularly. Increase in size of nodules or loss of definition of their margins necessitate further investigations, such as CT scans or MRI. In addi- tion, serum D-fetoprotein and carcino-embryonal antigen can be used to screen for malignant transformation. How- ever, neither CT nor MRI are highly predictive of malignant transformation, and false negative results for both tumour markers have been reported [53]. The management of liver adenomas is either conservative or surgical. In severe cases of adenomas, enucleation or partial liver resection are ther- apeutic options. Where there is a recurrence of adenomas or suspected malignant transformation, liver transplanta- tion is a therapeutic option provided there are no metas- tases [54]. Liver transplantation also corrects glucose home- ostasis, but in GSD 1b does not correct neutropenia and neutrophil dysfunction, nor does it prevent the develop- ment of renal failure [55]. Immunosuppression may worsen renal function. Osteopenia appears to be a result of both decreased bone matrix formation and decreased mineralisation [56, 57]. Limited peak bone mass formation increases the risk of fractures later in life. It is important for normal bone forma- tion to suppress secondary metabolic and hormonal dis- turbances, especially chronic lactatemia. Anemia is observed at all ages, but especially in adoles- cent and adult patients [1, 43]. The anemia may be refrac- tory to iron because of inappropriate production, by hepatic adenomas, of hepcidin, a peptide hormone that controls the release of iron from intestinal cells and macrophages [58]. Polycystic ovaries (PCOs) have been observed in adoles- cent and adult female patients [59]. Their pathophysiology is unresolved and their effects on reproductive function are unclear. PCOs may cause acute abdominal pain as a result of vascular disturbances. This should be differentiated from pancreatitis and haemorrhage into liver adenoma. Despite severe hyperlipidemia, car d io vascular morbidity and mortality is infrequent and, when present, may be re- lated to secondary metabolic changes caused by the pro- gressive renal disease. The preservation of normal endothe- lial function [1, 43, 60] may result from diminished platelet aggregation [61], increased levels of apolipoprotein E [62], decreased susceptibility of LDL to oxidation – possibly re- lated to the altered lipoprotein fatty acid profile in GSD Ia [32] – and increased antioxidative defences in plasma pro- tecting against lipid peroxidation [31]. A vascular complication that may cause more morbid- ity and mortality in the ageing patient is pulmonary hyper- tension followed by progressive heart failure [63]. It may develop in the second decade or later. No specific treatment is available. Monitoring by ECG and cardiac ultrasonogra- phy is recommended after the first decade. Depressive illness needing therapy is observed rather frequently in adult patients [1, 43]. Lifelong intensive dietary treatment 24 hours a day, together with the threat of serious medical problems, is a major burden for both patients and their parents. Successful pregnancies have been reported [1, 33]. Close supervision and reintroduction of intensive dietary treat- ment is necessary. 6.1.2 Glycogen Storage Disease Type III (Debranching Enzyme Deficiency) The release of glucose from glycogen requires the activity of both phosphorylase and glycogen debranching enzyme (GDE). GSD III, also known as Cori or Forbes disease, is an autosomal recessive disorder due to deficiency of GDE which causes storage of glycogen with an abnormally com- pact structure, known as phosphorylase limit dextrin. Dif- ferences in tissue expression of the deficient GDE explain the existence of various subtypes of GDS III. Most patients with GSD III have a generalized defect in which enzyme activity is deficient in liver, muscle, heart, leukocytes and cultured fibroblasts, and have a syndrome that includes both hepatic and myopathic symptoms, and often cardio- myopathy (GSD IIIa). About 15% of patients only have symptoms of liver disease and are classified as GSD IIIb. Subgroups due to the selective deficiency of either the glu- cosidase activity (GSD IIIc) or of the transferase activity (GSD IIId) are very rare. Clinical Presentation Hepatic Presentation Hepatomegaly, short stature, hypoglycemia, and hyper- lipidemia predominate in children, and this presentation may be indistinguishable from GSD I. Splenomegaly can be present, but the kidneys are not enlarged and renal function is normal. With increasing age, these symptoms improve in most GSD III patients and may disappear around puberty. Myopathic Presentation Clinical myopathy may not be apparent in infants or chil- dren, although some show hypotonia and delayed motor milestones. Myopathy often appears in adult life, long after liver symptoms have subsided. Adult-onset myopathies may be distal or generalised. Patients with distal myopathy develop atrophy of leg and intrinsic hand muscles, often leading to the diagnosis of motor neurone disease or peri- pheral neuropathy [64]. The course is slowly progressive and the myopathy is rarely crippling. The generalised myo- pathy tends to be more severe, often affecting respiratory muscles. In the EMG, myopathic features are mixed with irritative features (fibrillations, positive sharp waves, 6 109 myotonic discharges), a pattern that may reinforce the diag- nosis of motor neurone disease in patients with distal muscle atrophy. Nerve conduction velocities are often d ecreased [65]. Although GDE works hand-in-hand with myophosphorylase and one would therefore expect GDE deficiency to cause symptoms similar to those of McArdle disease, cramps and myoglobinuria are exceedingly rare. Muscle biopsy typically shows a vacuolar myopathy. The vacuoles contain PAS-positive material and corresponds to large pools of glycogen, most of which is free in the cyto- plasm. However, some of the glycogen is present within lysosomes. Biochemical analysis shows greatly increased concentration of phosphorylase-limit dextrin, as expected. In agreement with the notion that the enzyme defect is generalised, peripheral neuropathy has been documented both electrophysiologically and by nerve biopsy and may contribute to the weakness and the neurogenic features of some patients. Similarly, while symptomatic cardiopathy is uncommon, cardiomyopathy (similar to idiopathic hyper- trophic cardiomyopathy) is detectable in virtually all pa- tients with myopathy [66]. Metabolic Derangement GDE is a bifunctional enzyme, with two catalytic activities, oligo-1,4o1,4-glucantransferase and amylo-1,6-gluco- sidase. After phosphorylase has shortened the peripheral chains of glycogen to about four glycosyl units, these re- sidual stubs are removed by GDE in two steps. A maltotriosyl unit is transferred from a donor to an acceptor chain (trans- ferase activity), leaving behind a single glucosyl unit, which is hydrolysed. During infancy and childhood patients suffer from fasting hypoglycemia, associated with ketosis and hyper- lipidemia. Serum transaminases are also increased in child- hood but decrease to (almost) normal values with increas- ing age. In contrast to GSD I, blood lactate concentration is normal. Elevated levels of serum creatine kinase (CK) and aldolase suggest muscle involvement, but normal values do not exclude the future development of myopathy. Genetics The gene for GDE (GDE) is located on chromosome 1p21. At present, at least 48 different mutations in the GDE gene have been associated with GSD III. GSD IIIb is associated with mutations in exon 3, while mutations beyond exon 3 are associated with GSD IIIa. When all known GSD III mutations are taken into consideration, there is no clear correlation between the type of mutation and the severity of the disease. This makes prognostic counselling based on mutations difficult [67]. Diagnosis Diagnosis is based on enzyme studies in leukocytes, erythro- cytes and/or fibroblasts, combined with DNA investigations in leukocytes. Prenatal diagnosis is possible by identifying mutations in the GDE gene if these are already known. If not, polymorphic markers may be helpful in informative families. Prenatal diagnosis based on GDE activity in cul- tured amniocytes or chorionic villi is technically difficult and does not always discriminate between the carrier state and the affected fetus. Treatment The main goal of dietary treatment is prevention of hypo- glycemia and correction of hyperlipidemia. Dietary man- agement is similar to GSD Ia but, since the tendency to develop hypoglycemia is less marked, only some younger patients will need continued nocturnal gastric drip feeding, and a late evening meal and/or uncooked corn starch will be sufficient to maintain normoglycemia during the night. In GSD III (as opposed to GSD I), restriction in fructose and galactose is unnecessary and dietary protein intake can be increased since no renal dysfunction exists. The latter would not only have a beneficial effect on glucose homeos- tasis, but also on atrophic myopathic muscles. Complications, Prognosis, Pregnancy With increasing age, both clinical and biochemical abnor- malities gradually disappear in most patients; parameters of growth normalise, and hepatomegaly usually disappears after puberty [43]. In older patients, however, liver fibrosis may develop into cirrhosis. In about 25% of these patients, liver adenoma may occur, and transformation into hepato- cellular carcinoma has been described, although this risk is apparently small. Liver transplantation has been performed in patients with end-stage cirrhosis and/or hepatocellular carcinoma [55, 66]. Generally, prognosis is favourable for the hepatic form (GSD IIIb), whereas it is less favourable for GSD IIIa, be- cause severe progressive myopathy and cardiomyopathy may develop even after a long period of latency. Currently there is no satisfactory treatment for either the myopathy or cardiomyopathy. Successful pregnancy has been reported; regular dietary management with respect to the increasing needs for energy (carbohydrates) and nutrients is warranted [68]. 6.1.3 Glycogen Storage Disease Type IV (Branching Enzyme Deficiency) GSD IV, or Andersen Disease, is an autosomal recessive disorder due to a deficiency of glycogen branching enzyme (GBE). Deficiency of GBE results in the formation of an amylopectin-like compact glycogen molecule with fewer branching points and longer outer chains. The pathophysi- ological consequences of this abnormal glycogen for the liver still need to be elucidated. Patients with the classical form of GSD IV develop progressive liver disease early in life. The non-progressive hepatic variant of GSD IV is less 6.1 · The Liver Glycogenoses Chapter 6 · The Glycogen Storage Diseases and Related Disorders110 II frequent and these patients usually survive into adulthood. Besides these liver related presentations, there are rare neuro muscular forms of GSD IV. Clinical Presentation Hepatic Forms Patients are normal at birth and present generally in early childhood with hepatomegaly, failure to thrive, and liver cirrhosis. The cirrhosis is progressive and causes portal hypertension, ascites, and oesophageal varices. Some pa- tients may also develop hepatocellular carcinoma [69]. Life expectancy is limited due to severe progressive liver failure and – without liver transplantation – death generally occurs when patients are 4 to 5 years of age [70, 71]. Patients with the non-progressive form present with hepatomegaly and sometimes elevated transaminases. Although fibrosis can be detected in liver biopsies, this is apparently non-progressive. No cardiac or skeletal muscle involvement is seen. These patients have normal parameters for growth. Neuromuscular Forms Neuromuscular forms can be divided into four clinical presentations according to the age of onset. A neonatal form, which is extremely rare, presents as fetal akinesia d eformation sequence (FADS), consisting of arthrogryposis multiplex congenita, hydrops fetalis, and perinatal death. A congenital form presents with hypotonia, cardiomyo- pathy, and death in early infancy. A third form manifests in childhood with either myopathy or cardiomyopathy. Lastly, the adult form may present as a myopathy or as a multi- systemic disease also called adult polyglucosan body dis- ease (APBD) [72]. APBD is characterised by progressive upper and lower motor neurone dysfunction (sometimes simulating amyotrophic lateral sclerosis), sensory loss, sphincter problems and, inconsistently, dementia. In APBD, polyglucosan bodies have been described in processes (not perikarya) of neurones and astrocytes in both grey and white matter. Muscle biopsy in the neuromuscular forms shows the typical foci of polyglucosan accumulation, intensely PAS- positive and diastase-resistant. Similar deposits are seen in the cardiomyocytes of children with cardiomyopathy and in motor neurones of infants with Werdnig-Hoffmann-like presentation [73]. Metabolic Derangement Hypoglycemia is rarely seen, and only in the classical hepatic form, when liver cirrhosis is advanced, and detoxification and synthesis functions become impaired. The clinical and biochemical findings under these circumstances are identical to those typical of other causes of cirrhosis, with elevated liver transaminases and abnormal values for blood clotting factors, including prothrombin and thromboplas- tin generation time. Genetics The GBE gene has been mapped to chromosome 3p14. Three important point mutations, R515C, F257L and R524X were found in patients with the classical progressive liver cirrhosis form [74]. In patients with the non-progressive liver form, the Y329S mutation has been reported. This mutation results in a significant preservation of GBE activity, thereby explaining the milder course of the disease [70]. Interestingly, the mutation found in patients with APBD [72] also appears to be relatively mild [74] which may explain the late onset of this disorder. Diagnosis The diagnosis is usually only suspected at the histological examination of a liver or muscle biopsy which shows large deposits that are periodic-acid-Schiff-staining but partially resistant to diastase digestion. Electron microscopy shows accumulation of fibrillar aggregations that are typical for amylopectin. The enzymatic diagnosis is based on the d emonstration of GBE deficiency in liver, muscle, fibro- blasts, or leukocytes. Prenatal diagnosis is possible using DNA mutation analysis in informative families, but difficult by measuring the enzyme activity in cultured amniocytes or chorionic villi because of high residual enzyme activity. Treatment There is no specific dietary treatment for GSD IV. Dietary treatment focuses on the maintenance of normoglycemia by frequent feedings and a late evening meal.Liver trans- plantation is the only effective therapeutic approach at present for GSD IV patients with the classic progressive liver disease [55, 71]. Complications, Prognosis, Pregnancy The ultimate prognosis depends on the results of liver trans- plantation which was favourable in 13 GSD IV patients [55]. The prognosis also depends on the occurrence of amylo- pectin storage in extra-hepatic tissues. This risk seems to be especially high for cardiac tissue. Of 13 patients with GSD IV who underwent liver transplantation, two died from heart failure due to amylopectin storage in the myo- cardium [55]. A positive result of liver transplantation may be the development of systemic microchimerism, with d onor cells present in various tissues. This would lead to a transfer of enzyme activity from normal to deficient cells outside the liver [70]. No pregnancies are reported in clas- sical GSD IV. Patients with the non-progressive liver variant have been reported to survive into their mid forties. With in- creasing age, liver size tends to decrease and elevated trans- aminases return to (nearly) normal values. 6 111 6.1.4 Glycogen Storage Disease Type VI ( Glycogen Phosphorylase Deficiency) GSD VI or Hers disease is an autosomal recessive disorder due to a deficiency of the liver isoform of glycogen phos- phorylase. Phosphorylase breaks the straight chains of gly- cogen down to glucose-1-phosphate in a concerted action with debranching enzyme. Glucose-1-phosphate in turn is converted into glucose-6-phosphate and then into free glucose. Clinical Presentation GSD VI is a rare disorder with a generally benign course. Patients are clinically indistinguishable from those with liver GSD type IX caused by phosphorylase kinase (PHK) deficiency and present with hepatomegaly and growth retardation in early childhood. Cardiac and skeletal muscles are not involved. Hepatomegaly decreases with age and usually disappears around puberty. Growth usually nor- malises after puberty [66]. Metabolic Derangement The tendency towards hypoglycemia is not as severe as seen in GSD I or GSD III and usually appears only after pro- longed fasting in infancy. Hyperlipidemia and hyperketosis are usually mild. Lactic acid and uric acid are within normal limits. Genetics Three isoforms of phosphorylase are known, encoded by three different genes. The gene encoding the liver isoform, PYGL, is on chromosome 14q21-q22, and mutations have been described [75]. Diagnosis Deficient phosphorylase activity can be documented in liver tissue. Treatment Treatment of liver phosphorylase deficiency is symptomatic, and consists of preventing hypoglycemia using a high-carbo- hydrate diet and frequent feedings; a late evening meal is unnecessary in most patients. 6.1.5 Glycogen Storage Disease Type IX (Phosphorylase Kinase Deficiency) GSD IX, or phosphorylase kinase (PHK) deficiency, is the most frequent glycogen storage disease. According to the mode of inheritance and clinical presentation six different subtypes are distinguished: (1) X-linked liver glycogenosis (XLG or GSD IXa), by far the most frequent subtype; ( 2) combined liver and muscle PHK deficiency (GSD IXb); (3) autosomal liver PHK deficiency (GSD IXc); (4) X-linked muscle glycogenosis (GSD IXd); (5) autosomal muscle PHK deficiency (GSD IXe); and (6) heart PHK deficiency (GSD IXf) with the mode of inheritance not clear yet [75, 76 ], but probably due to AMP kinase mutations [76a]. Clinical Presentation Hepatic Presentation The main clinical symptoms are hepatomegaly due to glyco- gen storage, growth retardation, elevated liver transami- nases, and hypercholesterolemia and hypertriglyceridemia. Symptomatic hypoglycemia and hyperketosis are only seen after long periods of fasting in young patients. The clinical course is generally benign. Clinical and biochemical abnor- malities disappear with increasing age and after puberty most patients are asymptomatic [77, 78]. Myopathic Presentation Not surprisingly, the myopathic variants present clinically similar to a mild form of McArdle disease ( 7 below), with exercise intolerance, cramps, and recurrent myoglobinuria in young adults. Less frequent presentations include infan- tile weakness and respiratory insufficiency or late-onset weakness. Muscle morphology shows subsarcolemmal de- posits of normal-looking glycogen. Metabolic Derangement The degradation of glycogen is controlled both in liver and in muscle by a cascade of reactions resulting in the activa- tion of phosphorylase. This cascade involves the enzymes adenylate cyclase and PHK. PHK is a decahexameric pro- tein composed of four subunits, D, E, J, and G: the Dand E subunits are regulatory, the J subunit is catalytic, and the Gsubunit is a calmodulin and confers calcium sensitivity to the enzyme. The hormonal activating signals for glycoge- nolysis are glucagon for the liver and adrenaline for muscle. Glucagon and adrenaline activate the membrane-bound adenylate cyclase, which transforms ATP into cyclic AMP (cAMP) and interacts with the regulatory subunit of the cAMP-dependent protein kinase, resulting in phosphoryla- tion of PHK. Ultimately, this activated PHK transforms glycogen phosphorylase into its active conformation, a process which is defective in GSD type IX. Genetics Two different isoforms of the Dsubunit (D L for liver and D M for muscle) are encoded by two different genes on the X chromosome (PHKA2 and PHKA1 respectively), while the Esubunit (encoded by PHKB), two different isoforms of the J subunit (J T for testis/liver and J M for muscle, encoded by PKHG2 and PKHG1, respectively), and three isoforms of calmodulin (CALM1, CALM2, CALM3) are encoded by autosomal genes. The PHKA2 gene has been mapped to chromosome Xp22.2-p22.1, the PHKB gene to chromosome 16q12-q13, and the PKHG2 gene to chromo- some 16p12-p11 [75, 79, 80]. 6.1 · The Liver Glycogenoses [...]... 8.1.2 8.1 .3 8.1.4 8.1.5 Clinical Presentation – 133 Metabolic Derangement – 133 Genetics – 133 Diagnostic Tests – 133 Treatment and Prognosis – 133 8.2 Transaldolase Deficiency 8.2.1 8.2.2 8.2 .3 8.2.4 8.2.5 Clinical Presentation – 133 Metabolic Derangement – 134 Genetics – 134 Diagnostic Tests – 134 Treatment and Prognosis – 134 References – 134 – 133 132 Chapter 8 · Disorders of the Pentose Phosphate... 9.1 .3 9.1.4 9.1.5 Clinical Presentation – 137 Metabolic Derangement – 137 Genetics – 137 Diagnosis – 137 Treatment and Prognosis – 137 – 137 9.2 Hereditary Fructose Intolerance 9.2.1 9.2.2 9.2 .3 9.2.4 9.2.5 9.2.6 Clinical Presentation – 137 Metabolic Derangement – 138 Genetics – 138 Diagnosis – 138 Differential Diagnosis – 139 Treatment and Prognosis – 139 9 .3 Fructose-1,6-Bisphosphatase Deficiency 9 .3. 1... Ribose-5-phosphate isomerase deficiency is a block in the reversible part of the pentose phosphate pathway In theory, this defect leads to a decreased capacity to interconvert ribulose-5-phosphate and ribose-5-phosphate and results in the formation of sugars and polyols: ribose and ribitol from ribose-5-phosphate and xylulose and arabitol from ribulose-5-phosphate via xylulose-5-phosphate 8.1 .3 Genetics... galactosemia J Pediatr 137 : 83 3- 8 41 Webb AL, Singh RH, Kennedy MJ et al (20 03) Verbal dyspraxia and galactosemia Pediatr Res 53: 39 6-4 02 Jakobs C, Kleijer WJ, Allen J et al (1995) Prenatal diagnosis of galactosemia Eur J Pediatr 154[Suppl 2]:S 3 3- S36 Beigi B, O’Keefe M, Bowell R et al (19 93) Ophthalmic findings in classical galactosaemia – prospective study Br J Ophthalmol 77:16 2-1 64 Vogt M, Gitzelmann... feeding first and only then seek a diagnosis! « 7.1 Deficiency of Galactose-1-Phosphate Uridyltransferase – 1 23 7.1.1 7.1.2 7.1 .3 7.1.4 7.1.5 Clinical Presentation – 1 23 Metabolic Derangement – 1 23 Genetics – 1 23 Diagnostic Tests – 124 Treatment and Prognosis – 124 7.2 Uridine Diphosphate-Galactose 4'-Epimerase Deficiency – 126 7.2.1 7.2.2 7.2 .3 7.2.4 7.2.5 Clinical Presentation – 126 Metabolic Derangement... MTP, Lancaster, pp 12 5-1 32 43 Gitzelmann R, Steinmann B (1984) Galactosemia: How does longterm treatment change the outcome? Enzyme 32 :3 7-4 6 44 Holton JB (1996) Galactosaemia: pathogenesis and treatment J Inherit Metab Dis 19: 3- 7 45 Bosch AM, Grootenhuis MA, Bakker HD et al (2004) Living with classical galactosemia: health-related quality of life consequences Pediatrics 1 13( 5) 42 3- 4 28 46 Irons M, Levy... Derangement – 126 Genetics – 126 Diagnostic Tests – 127 Treatment and Prognosis – 127 7 .3 Galactokinase Deficiency 7 .3. 1 7 .3. 2 7 .3. 3 7 .3. 4 7 .3. 5 Clinical Presentation – 127 Metabolic Derangement – 127 Genetics – 127 Diagnostic Tests – 127 Treatment and Prognosis – 128 7.4 Fanconi-Bickel Syndrome 7.5 Portosystemic Venous Shunting and Hepatic Arterio-Venous Malformations – 128 References – 128 – 127 – 128... inherited metabolic myopathy and hemolysis due to a mutation in aldolase A N Engl J Med 33 4:110 0-1 104 1 03 Comi GP, Fortunato F, Lucchiari S et al (2001) Beta-enolase deficiency, a new metabolic myopathy of distal glycolysis Ann Neurol 50:20 2-2 07 104 Kanno T, Maekawa M (1995) Lactate dehydrogenase M-subunit deficiencies: clinical features, metabolic background, and genetic heterogeneities Muscle Nerve 3: S54-S60... 9 .3. 1 9 .3. 2 9 .3. 3 9 .3. 4 9 .3. 5 9 .3. 6 Clinical Presentation – 140 Metabolic Derangement – 140 Genetics – 141 Diagnosis – 141 Differential Diagnosis – 141 Treatment and Prognosis – 141 References – 142 – 137 – 140 136 Chapter 9 · Disorders of Fructose Metabolism Fructose Metabolism II Fructose is one of the main sweetening agents in the human diet It is found in its free form in honey, fruits and many... amino acid substitutions, A150P , A175D, and N 335 K are relatively common among patients of central European descent and have been detected in 65%, 11% and 8% of mutated alleles, respectively [11, 12] Some mutations may be found particularly in certain ethnic groups, such as the N 335 K and c .36 0 -3 63 del CAAA mutations in the populations of the former Yugoslavia and Sicily, respectively Since the three . disease. J Pediatr 119 :39 8-4 03 13. Alaupovic P, Fernandes J (1985) The serum apolipoprotein profile of patients with glucose-6-phosphatase deficiency. Pediatr Res 19 :38 0 -3 84 14. Bandsma RH, Smit. 127 7.2.5 Treatment and Prognosis – 127 7 .3 Galactokinase Deficiency – 127 7 .3. 1 Clinical Presentation – 127 7 .3. 2 Metabolic Derangement – 127 7 .3. 3 Genetics – 127 7 .3. 4 Diagnostic Tests – 127 7 .3. 5 Treatment. first and only then seek a diagnosis! « 7.1 Deficiency of Galactose-1-Phosphate Uridyltransferase – 1 23 7.1.1 Clinical Presentation – 1 23 7.1.2 Metabolic Derangement – 1 23 7.1 .3 Genetics – 1 23 7.1.4