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Chapt e r

11
Principles of Molecular Disease:
Lessons from the Hemoglobinopathies

A molecular disease is one in which the primary disease- are being made weekly. Although it is impressive that
causing event is a mutation, either inherited or acquired. the basic molecular defect has been found in so many
This chapter outlines the basic genetic and biochemical disorders, it is sobering to realize that the pathophysi-
mechanisms underlying genetic disease, using disorders ological process is not entirely understood for any
of hemoglobin—the hemoglobinopathies—as exam- genetic disease. Sickle cell disease (Case 37) , discussed
ples. This overview of mechanisms is expanded in later in this chapter, is among the best characterized of
Chapter 12 to include other genetic diseases that are inherited disorders, but even here, knowledge is incom-
important because they illustrate additional principles plete—despite its being the fi rst molecular disease to be
of genetics in medicine. recognized more than 50 years ago. Nevertheless, the
Knowledge of molecular pathology is the founda- study of genetic disease at its various phenotypic levels
tion of rational therapy and management for genetic (gene, protein, cell, tissue, whole body) has not only
diseases. Moreover, such knowledge is also often greatly informed medicine but also, as described in
instructive about normal function. The study of pheno- Chapter 13, led to increasingly promising treatment,
type at the level of proteins, biochemistry, and metabo- including protein and gene therapy, of inherited
lism constitutes the discipline of biochemical genetics. disorders.
A genetic disease occurs when an alteration in the DNA
of an essential gene changes the amount or function, or
both, of the gene products—messenger RNA (mRNA) THE EFFECT OF MUTATION ON
and protein. Single-gene disorders almost always result PROTEIN FUNCTION
from mutations that alter the function of a protein. The
few known exceptions to this generalization are muta- Mutations have been found to cause disease through
tions found in genes for RNAs that do not encode pro- one of four different effects on protein function (Fig.
teins, including mitochondrial genes that encode 11-1). The most common effect by far is a loss of func-
transfer RNAs (tRNAs); these mitochondrial tRNA tion of the protein. Many important conditions arise,
mutations can lead to serious neurological conditions however, from one of three other mechanisms: a gain
affecting muscle or brain (see Chapter 12). of function; the acquisition of a novel property by the
Understanding the pathogenesis of a genetic disease mutant protein; or the expression of a gene at the wrong
is not possible without knowledge of the primary bio- time (heterochronic expression) or in the wrong place
chemical abnormalities that result from the alteration (ectopic expression), or both.
in gene function. By 2007, the online version of Men-
delian Inheritance in Man (OMIM) listed just over Loss-of-Function Mutations
3900 diseases (both autosomal and X-linked) with
mendelian patterns of inheritance. Of these, 3310 or The loss of function of a gene may result from altera-
about 85% are known to be caused by mutations in tion of its coding, regulatory, or other critical sequences
over 1990 genes, and new disease gene identifications due to the introduction of nucleotide substitutions,

323
324 Thompson & Thompson GENETICS IN MEDICINE

MUTATION

Mutations in Mutations disrupting Mutations affecting


coding region RNA stability gene regulation
or or dosage
RNA splicing

Protein abnormal Protein structure normal

Decreased
• Hb Hammersmith (if unstable decreased amount) amount

CAUSE OF DISEASE • α-thalassemias


• β-thalassemias • Monosomies
• Tumor-suppressor
Increased
mutations
Loss of protein function amount
• Hb Kempsey
(the great majority)
• Achondroplasia • Trisomies
• Charcot-Marie-Tooth
Gain of function disease type 1A

• HPFH
• Hb S
Novel property • Many oncogenes
(infrequent)
Inappropriate
expression
(wrong time, place)
Ectopic or
heterochronic expression
(uncommon, except in cancer)

Figure 11-1 ■ A general outline of the mechanisms by which disease-causing mutations produce disease. Mutations in the
coding region result in structurally abnormal proteins that have a loss or gain of function or a novel property that causes
disease. Mutations in noncoding sequences are of two general types: those that alter the stability or splicing of the mRNA,
and those that disrupt regulatory elements or change gene dosage. Mutations in regulatory elements alter the abundance of
the mRNA or the time or cell type in which the gene is expressed. Mutations in either the coding region or regulatory domains
can decrease the amount of the protein produced. HPFH, hereditary persistence of fetal hemoglobin.

deletions, insertions, or rearrangements. A loss of func- the severity of a disease that results from loss-of-
tion due to deletion, leading to a reduction in gene function mutations can generally be correlated to the
dosage, is exemplified by the α-thalassemias (Case 39) , amount of function lost. In many instances, the reten-
which are most commonly due to deletion of α-globin tion of a small degree of residual function by the mutant
genes (see later discussion); by chromosome-loss protein greatly reduces the severity of the disease, a
diseases (Case 24) , such as monosomies like Turner syn- situation illustrated by the enzyme defects associated
drome (see Chapters 5 and 6 and Case 42 ); and by with hyperphenylalaninemia, the most severe form of
acquired somatic mutations—often deletions—that which is phenylketonuria (see Chapter 12).
occur in tumor-suppressor genes in many cancers (such
as retinoblastoma (Case 34) ; see Chapter 16). Many Gain-of-Function Mutations
other types of mutations can also lead to a complete
loss of function. These include the introduction of a Mutations may also alter the biochemical phenotype by
premature stop codon or of a missense or other muta- enhancing one or more of the normal functions of a
tion in the coding sequence that abolishes or impairs protein. In a biological system, more is not necessarily
protein function, or that renders the protein unstable, better, however, and disease may result. A gain in
thereby reducing its abundance. All of these classes of protein function may be due to either an increase in the
mutation, and others, are illustrated by the β- abundance of the protein, usually from an increase in
thalassemias (Case 39) (see later discussion), a group of its expression or that of its cognate gene, or an increase
hemoglobinopathies that result from a reduction in the in the ability of each protein molecule to perform one
abundance of β-globin, one of the major adult hemo- or more normal functions. It is critical to recognize
globin proteins in red blood cells. As might be expected, when a disease is due to a gain-of-function mutation
CHAPTER 11 ● Principles of Molecular Disease: Lessons from the Hemoglobinopathies 325

because treatment of the resulting disease must neces- hemoglobin, sickle hemoglobin chains aggregate when
sarily differ from disorders that arise from other mech- they are deoxygenated to form polymeric fibers that
anisms, such as loss-of-function mutations. Moreover, deform red blood cells. This behavior has not been
gain-of-function mutations often provide insight into observed with any other hemoglobin mutant. That
the regulation of the expression of the affected gene or novel property mutations are infrequent is not surpris-
protein and the molecular mechanism of the protein’s ing because most amino acid substitutions are either
function. neutral or detrimental to the function or stability of a
Mutations That Enhance One Normal Function of a protein that has been fi nely tuned by evolution. Only
Protein Rarely, a mutation in the coding region may rarely does a mutation introduce a new property of
increase the ability of each protein molecule to perform pathological significance.
a normal function even though it is detrimental to the The difficulty in placing every type of mutation
overall physiological activity of the protein. Once again, into one or another of the classes discussed in this
mutations in globin genes are among the best under- section is demonstrated by a recently discovered group
stood of mutations of this type and include missense of mutations, those that lead to gains of glycosylation.
mutations such as hemoglobin Kempsey, which locks In disorders of this type, a mutation in the coding
hemoglobin in its high oxygen affi nity state, thereby sequence creates a novel N-glycosylation site in the
reducing oxygen delivery to tissues. Another example mutant protein, conferring on it a novel property, the
of this phenomenon occurs in the form of short stature ability to be N-glycosylated. However, the increased
called achondroplasia (Case 1) . Mutations of this type, glycosylation leads to a loss of function of the mutant
which lead to the increase of a normal function, should protein, as has been documented in some individuals
be distinguished from novel property mutations (see with mutations in the R2 subunit of the interferon-γ
later), which result in the acquisition of a completely receptor, leading to a mendelian susceptibility to myco-
new function by the mutant protein. bacterial infection (see Chapter 12).
Mutations That Increase Production of a Normal Pro-
tein Some mutations cause disease by increasing the Mutations Associated with Heterochronic or
synthesis of a normal protein in cells in which the Ectopic Gene Expression
protein is normally present (in contrast to ectopic
An interesting and important class of mutations includes
expression). The most common mutations of this type
those that alter the regulatory regions of a gene to cause
are due to increased gene dosage, as with the presence
its inappropriate expression, at an abnormal time or
of three or more copies of an autosomal gene, which is
place. One of the most common genetic diseases, cancer,
generally the result of the duplication of part or all of
is frequently due to the abnormal expression of a gene
a chromosome, as in trisomy 21 (Down syndrome; see
that normally promotes cell proliferation—an onco-
Chapter 6). Other important diseases that arise from
gene—in cells in which the gene is not normally
the increased dosage of single genes include one form
expressed, resulting in malignant neoplasia (see Chapter
of familial Alzheimer disease, which is due to a duplica-
16). Comparably, some mutations in hemoglobin regu-
tion of the amyloid precursor protein (βAPP) gene (see
latory elements lead to the continued expression in the
Chapter 12), and the peripheral nerve degeneration
adult of the γ-globin gene, which is normally expressed
Charcot-Marie-Tooth disease type 1A (Case 6) , which
at high levels only in fetal life. Such γ-globin gene muta-
generally results from duplication of only one gene, the
tions lead to a phenotype called the hereditary persis-
gene for peripheral myelin protein 22 (PMP22).
tence of fetal hemoglobin (see later discussion).
Increases in gene dosage are also prevalent as somatic
mutations in cancer cells, where they result from
increased copies of part or all of a chromosome; HOW MUTATIONS DISRUPT THE
mutations of this type more often contribute to tumor FORMATION OF BIOLOGICALLY
progression than to initiation (discussed in Chapter
16).
NORMAL PROTEINS

Novel Property Mutations For development of a biologically active protein, infor-


mation must be transcribed from the nucleotide
In a few diseases, a change in the amino acid sequence sequence of the gene to the mRNA and then translated
causes disease by conferring a novel property on the into the polypeptide, which then undergoes progressive
protein, without necessarily altering its normal func- stages of maturation (see Chapter 3). Mutations can
tions. The classic example is sickle cell disease (Case 37) disrupt any of these steps (Table 11-1). Abnormalities
(see later discussion), which is due to an amino acid in five of these stages are illustrated by various hemo-
substitution that has no effect on the ability of sickle globinopathies; the others are exemplified by diseases
hemoglobin to transport oxygen. Rather, unlike normal presented in Chapter 12.