PROTEIN

METABOLISM

MR.CONRAD ONDIEKI MIRUKA

DEPARTMENT OF BIOCHEMISTRY
KIU-WESTERN CAMPUS
 Degradation of amino acids
— The -amino group is removed first and the resulting
carbon skeleton is converted into one or more major
metabolic intermediates and used as metabolic fuel
— The carbon skeletons of the 20 standard amino acids
are funneled into only seven molecules:
i. Pyruvate
ii. Acetyl CoA
iii. Acetoacetyl CoA
iv. α-ketoglutarate
v. Succinyl CoA
vi. Fumarate
vii. Oxaloacetate
Fate of carbon skeletons of amino
acids
Glucogenic and Ketogenic amino
acids
— Amino acids that are degraded to pyruvate, α-
ketoglutarate, succinyl CoA, fumarate and
oxaloacetate are termed glucogenic because they
can give rise to the net synthesis of glucose
— This is because the citric acid cycle intermediates and
pyruvate can be converted into phosphoenolpyruvate
and then into glucose via gluconeogenesis
— Amino acids that are degraded to acetyl CoA or
acetoacetyl CoA are termed ketogenic because they
give rise to ketone bodies
— The acetyl CoA or acetoacetyl CoA can also be used
to synthesize lipids
Glucogenic and Ketogenic amino
acids
— Of the standard set of 20 amino acids, only Leu and
Lys are solely ketogenic
— Ile, Phe, Trp and Tyr are both ketogenic and
glucogenic as some of their carbon atoms end up in
acetyl CoA or acetoacetyl CoA, whereas others end
up in precursors of glucose
— The remaining 14 amino acids are classified as solely
glucogenic
 Transamination
— This is the process by which the α-amino group of the
amino acid is first removed prior to the metabolism of their
carbon skeletons into a major metabolic intermediate
— In this process the α-amino group of most amino acids is
transferred to α-ketoglutarate to form glutamate and the
corresponding α-keto acid
— The enzymes that catalyze these reactions are called
transaminases (aminotransferases)
— In mammals, these enzymes are found predominantly in
the liver and muscle
— For example, aspartate transaminase catalyzes the
transfer of the amino group of aspartate to α-ketoglutarate
while alanine transaminase catalyzes the transfer of the
amino group of alanine to α-ketoglutarate
Transamination
 Clinical correlate
— Although the aminotransferases are in liver and
muscle, in pathologic conditions these enzymes may
leak into the blood where they are useful clinical
indicators of damage to liver or muscle

What conditions are associated with

elevated levels of ALT(formerly GPT)
and AST(formerly GOT) in blood?
The two most important aminotransferase reactions are
catalyzed by:
– Alanine aminotransferase (ALT): Present in many
tissues. The enzyme catalyzes the transfer of the amino
group of alanine to α-ketoglutarate, resulting in the
formation of pyruvate and glutamate. The reaction is
readily reversible. However, during amino acid
catabolism, this enzyme functions in the direction of
glutamate synthesis.
– Aspartate aminotransferase (AST): AST transfers
amino groups from glutamate to oxaloacetate, forming
aspartate, which is used as a source of nitrogen in the
urea cycle.

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 Transaminations
Glutamate-Pyruvate
Aminotransferase
Glutamate (Alanine Transferase ALT) -Ketoglutarate
+ +
Pyruvate Alanine

Glutamate-Oxaloacetate
Glutamate Aminotransferase -Ketoglutarate
+ (Aspartate Transferase AST) +
Oxaloacetate Aspartate

Blood levels of these aminotransferases, also called transaminases,

are important indicators of liver disease

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Role of Pyridoxal phosphate in
transamination reactions
— The coenzyme (or prosthetic group) of all
transaminases is pyridoxal phosphate, which is
derived from pyridoxine (vitamin B6)
— The coenzyme is transiently converted into
pyridoxamine phosphate during transamination
— In the absence of substrate, the aldehyde group of
pyridoxal phosphate forms a covalent Schiff base
linkage (imine bond) with the amino group in the
side-chain of a specific lysine residue in the active site
of the enzyme
 Role of Pyridoxal phosphate in
transamination reactions
— On addition of substrate, the -amino group of the
incoming amino acid displaces the amino group of the
active site lysine
— A new Schiff base linkage is formed with the amino
acid substrate
— The resulting amino acid–pyridoxal phosphate–Schiff
base that is formed remains tightly bound to the
enzyme by multiple noncovalent interactions
— Pyridoxal phosphate is also the coenzyme for several
other reactions involving amino acids including
decarboxylations, deaminations, racemizations and
aldol cleavages
 Role of Pyridoxal phosphate in
transamination reactions
 Oxidative deamination of glutamate
— The α-amino groups that have been funneled into
glutamate from the other amino acids are then
converted into ammonia by the action of glutamate
dehydrogenase
— This enzyme is unusual in being able to utilize either
NAD+ or NADP+
— In the biosynthesis of glutamate, the NADP+ form of
the coenzyme is used, whereas NAD+ is used in its
degradation
— GTP and ATP are allosteric inhibitors of glutamate
dehydrogenase
— GDP and ADP are allosteric activators of the
enzyme
Oxidative deamination of glutamate
Importance of the allosteric
regulation
— When the energy charge of the cell is low (i.e. there is
more ADP and GDP than their triphosphate forms)
glutamate dehydrogenase is activated and the
oxidation of amino acids increases
— The resulting carbon skeletons are then utilized as
metabolic fuel, feeding into the citric acid cycle and
ultimately giving rise to energy through oxidative
phosphorylation
Alternative route for deamination of amino
acids
— The major route for the deamination of amino acids is
transamination followed by the oxidative deamination
of glutamate
— A minor route for deamination involves direct
oxidation of the amino acid by L-amino acid oxidase
— This enzyme utilizes flavin mononucleotide (FMN)
as its coenzyme
— The resulting FMNH2 is reoxidized by molecular O2
— This process also generates the toxic H2O2
— The H2O2 is rendered harmless by the action of
catalase
— Kidney and liver are also rich in the FAD-containing
D-amino acid oxidase
Alternative route for deamination of amino
acids
Disposal of ammonia formed from
deamination
— Ammonotelic organisms excrete ammonia directly,
uricotelic organisms excrete it as uric acid, and
ureotelic organisms excrete it as urea
— Terrestrial vertebrates (mammals included) convert
the ammonia into urea before excretion
— Urea is synthesized in the liver by the urea cycle
— It is then secreted into the bloodstream and taken up
by the kidneys for excretion in the urine
— The urea cycle was the first cyclic metabolic pathway
to be discovered
 Urea Cycle
— One of the nitrogen atoms of urea comes from
ammonia
— The other is transferred from the amino acid
aspartate
— The carbon atom comes from CO2
— Ornithine, an amino acid that is not in the standard
set of 20 amino acids and is not found in proteins, is
the carrier of these nitrogen and carbon atoms
— Five enzymatic reactions are involved in the urea
cycle
— The first two reactions take place in mitochondria
— The other three reactions take place in the cytosol
 Urea cycle
Reaction 1:
— Carbamoyl phosphate synthetase I catalyzes the
condensation and activation of ammonia (from the
oxidative deamination of glutamate by glutamate
dehydrogenase) and CO2 (in the form of bicarbonate,
HCO3–) to form carbamoyl phosphate
— The hydrolysis of two ATP molecules makes this
reaction essentially irreversible.
 Urea cycle
Reaction 2:
— The second reaction also occurs in the mitochondria
— It involves the transfer of the carbamoyl group from
carbamoyl phosphate to ornithine by ornithine
— Transcarbamoylase
— This reaction forms another nonstandard amino acid
citrulline
— Citrulline then has to be transported out of the
mitochondrion into the cytosol where the remaining
reactions of the cycle take place
 Urea cycle
Reaction 3:
— In the cytosol, the citrulline is then condensed with
aspartate, catalysed by the enzyme
argininosuccinate synthetase to form
argininosuccinate
— Aspartate is the source of the second nitrogen atom
in urea
— This reaction is driven by the hydrolysis of ATP to
AMP and PPi, with subsequent hydrolysis of the
pyrophosphate
— Thus both of the high-energy bonds in ATP are
ultimately cleaved
 Urea cycle
Reaction 4:
— The enzyme Argininosuccinase then removes the
carbon skeleton of aspartate from argininosuccinate
in the form of fumarate, leaving the nitrogen atom on
the other product arginine
— As the urea cycle also produces arginine, this amino
acid is classified as nonessential in ureotelic
organisms
— Arginine is the immediate precursor of urea
 Urea cycle
Reaction 5:
— The urea is then formed from arginine by the action of
arginase
— This reaction occurs with the subsequent
regeneration of ornithine
— The ornithine is then transported back into the
mitochondrion ready to be combined with another
molecule of carbamoyl phosphate
Genetic Deficiencies of Urea
Synthesis
Genetic Deficiencies of Urea
Synthesis
— These conditions can be treated with:
i. A low protein diet
ii. Administration of sodium benzoate
iii. Administration of phenylpyruvate
NB: The last two provide an alternative route for
capturing and excreting excess nitrogen
 Hyperammonemia
— A block in any of the urea cycle enzymes leads to an
increase in the amount of ammonia in the blood
— This is referred as hyperammonemia
— The most common cause of such a block is a genetic
defect that becomes apparent soon after birth
— The afflicted baby becomes lethargic and vomits
periodically
— If left untreated, coma and irreversible brain damage
will follow
— The cause of irreversible brain damage is not fully
understood
 Possible explanation for brain
damage in hyperammonemia
— Excess ammonia leads to the increased formation of
glutamate and glutamine
— These reactions result via depletion of the citric acid
cycle intermediate α-ketoglutarate
— This may then compromise energy production,
especially in the brain
— It also leads to an increase in the acidic amino acids
glutamate and glutamine which may directly cause
damage to the brain
 Possible explanation for brain
damage in hyperammonemia
AMMONIA TOXICITY
• The catabolic production of ammonia poses a serious
biochemical problem, because ammonia is very toxic.
• The terminal stages of ammonia intoxication in
humans are characterized by:
– onset of a comatose state
– cerebral edema
– increased cranial pressure
• Ridding the cytosol of excess ammonia requires
reductive amination of -ketoglutarate to glutamate
by glutamate dehydrogenase and conversion of
glutamate to glutamine by glutamine synthetase.

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• Both enzymes are present at high levels in the brain.
• High levels of NH4 lead to increased levels of
glutamine, which acts as an osmotically active solute
(osmolyte) in brain astrocytes.
• This triggers an uptake of water into the astrocytes to
maintain osmotic balance, leading to swelling and the
symptoms noted above.
• Glutamate and its derivative –aminobutyrate are
important neurotransmitters; the sensitivity of the
brain to ammonia may reflect a depletion of
neurotransmitters as well as changes in cellular
osmotic balance.

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Formation of Creatine phosphate
— The urea cycle is also the starting point for the
synthesis of another important metabolite creatine
phosphate.
— This compound provides a reservoir of high-energy
phosphate in muscle cells as the energy released
upon its hydrolysis is greater than that released upon
the hydrolysis of ATP
NB: ΔG for creatine phosphate hydrolysis = –10.3 kcal
mol–1
ΔG for ATP hydrolysis= –7.3 kcal mol–1
 Formation of Creatine
phosphate
— The first step in the formation of creatine phosphate
is the condensation of arginine and glycine to form
guanidinoacetate
— Ornithine is released in this reaction and can then be
re-utilized by the urea cycle
— The guanidinoacetate is then methylated by the
methyl group donor S-adenosyl methionine to form
creatine
— Creatine is in turn phosphorylated by creatine kinase
to form creatine phosphate
Catecholamines
— Include dopamine, norepinephrine, and epinephrine.
— Dopamine and norepinephrine function as
neurotransmitters in the brain and the autonomic
nervous system.
— Norepinephrine and epinephrine are also synthesized
in the adrenal medulla.

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Function
— Outside the nervous system, norepinephrine and its
methylated derivative, epinephrine, act as regulators
of carbohydrate and lipid metabolism.
— Norepinephrine and epinephrine are released from
storage vesicles in the adrenal medulla in response to
fright, exercise, cold, and low levels of blood glucose.
— They increase the degradation of glycogen and
triacylglycerol, as well as increase blood pressure and
the output of the heart.
— These effects are part of a coordinated response to
prepare the individual for emergencies, and are often
called the “fight-or-flight” reactions.

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Serotonin
— Serotonin, also called 5-hydroxytryptamine, is synthesized
and stored at several sites in the body .
— By far the largest amount of serotonin is found in cells of
the intestinal mucosa.
— Smaller amounts occur in the central nervous system,
where it functions as a neurotransmitter, and in platelets.
— Serotonin is synthesized from tryptophan, which is
hydroxylated in a reaction analogous to that catalyzed by
phenylalanine hydroxylase. The product, 5-
hydroxytryptophan, is decarboxylated to serotonin, which
is also degraded by MAO.
— Serotonin has multiple physiologic roles, including pain
perception, affective disorders, and regulation of sleep,
temperature, and blood pressure

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42
Creatine
— Creatine phosphate the phosphorylated derivative of
creatine found in muscle, is a high-energy compound
that can reversibly donate a phosphate group to
adenosine diphosphate to form ATP .
— Creatine phosphate provides a small but rapidly
mobilized reserve of high-energy phosphates that can
be use d to m a i n t a i n t h e i n t ra ce l l u l a r l e ve l o f
adenosine triphosphate (ATP) during the first few
minutes of intense muscular contraction.
— The amount of creatine phosphate in the body is
proportional to the muscle mass.

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44
 Melanin Formation
Tyr hydroxylase

O2
Tyrosine DOPA
Tyrosinase

Melanin Highly colored

(Black polymer) polymeric
intermediates

Melanin formed in skin (melanocytes), eyes, and hair

In skin, protects against sunlight Dopaquinone
Albinism: genetic deficiency of tyrosinase

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Specialized products derived from amino
acids
 Metabolic Defects in Amino Acid
Metabolism
— Inborn errors of metabolism are commonly caused by
mutant genes that generally result in abnormal
proteins, most often enzymes
— The inherited defects may be expressed as a total
loss of enzyme activity or, more frequently, as a
partial deficiency in catalytic activity
— Without treatment, the inherited defects of amino acid
metabolism almost invariably result in mental
retardation or other developmental abnormalities as a
result of harmful accumulation of metabolites
— Many are rare, occurring in less than 1 per 250,000 in
most populations
 Phenylketonuria
— Phenylketonuria (PKU), is caused by a deficiency of
phenylalanine hydroxylase
— PKU is the most common clinically encountered inborn
error of amino acid metabolism with a prevalence of 1 in
15,000 people
— Biochemically, it is characterized by accumulation of
phenylalanine and a deficiency of tyrosine
— Hyperphenylalaninemia may also be caused by
deficiencies in any of the several enzymes required to
synthesize BH4
— BH4 is required for tyrosine hydroxylase and tryptophan
hydroxylase, which catalyze reactions leading to the
synthesis of neurotransmitters, such as serotonin and
 Characteristics of classic
PKU
1. Elevated phenylalanine:
— Phenylalanine is present in elevated concentrations in
tissues, plasma, and urine
— Phenyllactate, phenylacetate, and phenylpyruvate are
also elevated in PKU
— These compounds are not normally produced in
significant amounts in the presence of functional
phenylalanine hydroxylase
— These metabolites give urine a characteristic musty
(“mousey”) odor
— The disease acquired its name from the presence of a
phenylketone (phenylpyruvate) in the urine
 Characteristics of classic
PKU
2. CNS symptoms:
— Mental retardation, failure to walk or talk, seizures,
hyperactivity, tremor, microcephaly, and failure to
grow constitute the characteristic findings in PKU
— The patient with untreated PKU typically shows
symptoms of mental retardation by the age of one
year, and rarely achieves an IQ greater than 50
 Characteristics of classic
PKU
3. Hypopigmentation:
— Patients with phenylketonuria often show a deficiency
of pigmentation (fair hair, light skin color, and blue
eyes)
— The hydroxylation of tyrosine by tyrosinase, which is
the first step in the formation of the pigment melanin,
is competitively inhibited by the high levels of
phenylalanine present in PKU
 Maternal PKU
— When women with PKU who are not on a low-
phenylalanine diet become pregnant, the offspring
are affected with “maternal PKU syndrome”
— High blood phenylalanine levels in the mother cause
microcephaly, mental retardation, and congenital
heart abnormalities in the fetus
— Some of these developmental responses to high
phenylalanine occur during the first months of
pregnancy
— For this reason, dietary control of blood phenylalanine
must begin prior to conception, and must be
maintained throughout the pregnancy
 Maple syrup urine disease
— Maple syrup urine disease (MSUD) is a rare condition
(1:185,000)
— It is an autosomal recessive disorder in which there is
a partial or complete deficiency in branched-chain α-
keto acid dehydrogenase
— This enzyme complex decarboxylates leucine,
isoleucine, and valine
— These amino acids and their corresponding α-keto
acids accumulate in the blood, causing a toxic effect
that interferes with brain functions
Maple syrup urine disease
 Maple syrup urine disease
— The disease is characterized by:
i. Feeding problems
ii. Vomiting
iii. Dehydration
iv. Severe metabolic acidosis
v. A characteristic maple syrup odor to the urine
— If untreated, the disease leads to mental retardation,
physical disabilities, and even death
 Treatment of Maple syrup urine
disease
— The disease is treated with a synthetic formula that
contains limited amounts of leucine, isoleucine, and
valine
— The formula is sufficient to provide the branched-
chain amino acids necessary for normal growth and
development without producing toxic levels
— Early diagnosis and lifelong dietary treatment is
essential if the child with MSUD is to develop
normally
— Branched-chain amino acids are an important energy
source in times of metabolic need
— Individuals with MSUD are at risk of decompensation
during periods of increased protein catabolism
 Albinism
— Albinism refers to a group of conditions in which a defect in
tyrosine metabolism results in a deficiency in the production of
melanin
— These defects result in the partial or full absence of pigment
from the skin, hair, and eyes
— Albinism appears in different forms, and it may be inherited by
one of several modes: autosomal recessive (primary mode),
autosomal dominant, or X-linked
— Complete albinism (also called tyrosinase-negative
oculocutaneous albinism) results from a deficiency of
tyrosinase activity
— This causes a total absence of pigment from the hair, eyes, and
skin
— It is the most severe form of the condition
— In addition to hypopigmentation, affected individuals have
vision defects and photophobia (sunlight hurts their eyes)
— They are at increased risk for skin cancer.
Albinism
 Sickle cell anemia
— Sickle-cell anemia (HbS) is the most common form of abnormal
hemoglobin. lt is so named because the erythrocytes of these
patients adopt a sickle shape (crescent like) at low oxygen
concentration.
Homozygous and heterozygous HbS :
Sickle cell anemia is said to be homozygous, if caused by inheritance
of two mutant genes (one from each parent) that code for p-chains.
In case of heterozygous HbS, only one gene (of p-chain) is affected
while the other is normal.

The erythrocytes of heterozygotes contain both HbS and HbA and the
disease is referred to as sickle cell trait which is more common
in blacks (almost 1 in 10 are affected).

The individuals of sickle-cell trait lead a normal life, and do not

usually show clinical symptoms. This is in contrast to
homozygous sickle-cell anemia
 Abnormalities associated with HbS

Sickle-cell anemia is characterized by the following abnormalities

— Life-long hemolytic anemia : The sickled erythrocytes are fragile
and their continuous breakdown leads to life-long anemia.

— Tissue damage and pain : The sickled cells block the capillaries
resulting in poor blood supply to tissues. This leads to extensive
damage and inflammation of certain tissues causing pain.

— Increased susceptibility to infection : Hemolysis and tissue

damage are accompanied by increased susceptibility to infection
and disease
— Premature death : Homozygous individuals of sickle-cell anemia
die before they reach adulthood (< 20 years)
in sickle-cell anemia

— Glutamate is a polar amino acid and it is replaced by a non-polar

valine in sickle-cell hemoglobin.

— This causes a marked decrease in the solubility of HbS in

deoxygenated form (T form). However, solubility of oxygenated
HbS is unaffected.

— The substitution of valine for glutamate results in a sticky patch

on the outer surface of p-chains. It is present on oxy- and
deoxyhemoglobin S but absent on HbA.
— There is a site or receptor complementary to sticky patch on
deoxy HbS.

— The sticky patch of one deoxy HbS binds with the receptor of
another deoxy HbS and this process continuous resulting in the
formation of long aggregate molecules of deoxy HbS

— Thus, the polymerization of deoxy HbS molecules leads to long

fibrous precipitates .

— These stiff fibres distort the erythrocytes into a sickle or crescent

shape. The sickled erythrocytes are highly vulnerable to lysis
ln case of oxy HbS, the complementary receptor is masked,
although the sticky patch is present .

Hence, the molecules of oxy HbS cannot bind among themselves or

with the molecules of deoxy HbS.

Normal deoxy HbA lacks sticky patches but contains receptors.

Absence of sticky patches does not allow the deoxy HbA to
participate in the formation of aggregates.

sickling is due to polymerization of deoxy HbS. Therefore, if HbS is

maintained in the oxygenated form (or with minimum deoxy HbS),
sickling can be prevented
 Sickle-cell trait provides resistance to malaria

— The incidence of sickle-cell disease coincides with the high

incidence of malaria in tropical areas of the world (particularly
among the black Africans).

— Sickle-cell trait (heterozygous state with about 40% HbS) provides

resistance to malaria which is a major cause of death in tropical
areas. This is explained as follows

— 1. Malaria is a parasitic disease caused by Plasmodium

falciparum in Africa. The malarial parasite spends a part of its life
cycle in erythrocytes. increased lysis of sickled cells (shorter life
span of erythrocytes) interrupts the parasite cycle.
2.More recent studies indicate that malarial parasite increases the
acidity of erythrocytes (pH down by 0.4).

The lowered pH increases the sickling of erythrocytes to about 40%

from the normally occurring 2Y". Therefore, the entry of malarial
parasite promotes sickling leading to lysis of erythrocytes.

Furthermore, the concentration of K+ is low in sickled cells which

is unfavorable for the parasite to survive.
— Sickle-cell trait appears to be an adaptation for the survival of the
individuals in malaria infested regions.

— Unfortunately, homozygous individuals, the patients of sickle-cell

anemia (much less frequent than the trait), cannot live beyond 20
years
 Diagnosis of sickle cell anemia

1. Sickling test : This is a simple microscopic examination of blood

smear prepared by adding reducing agents such as sodium
dithionite. Sickled erythrocytes can be detected under the
microscope.

2. Electrophoresis : When subjected to electrophoresis in alkaline

medium (pH 8.6), sickle-cell hemoglobin (HbS) moves slowly
towards anode (positive electrode) than does adult hemoglobin
(HbA). The slow mobility of HbS is due to less negative charge,
caused by the absence of glutamate residues that carry negative
charge.
In case of sickle-cell trait, the fast moving HbA and slow moving
HbS are observed.
The electrophoresis of hemoglobin obtained from lysed erythrocytes
can be routinely used for the diagnosis of sickle cell anemia and
sickle-cell trait.

Management of sickle cell disease

— Administration of sodium cyanate inhibits sickling of erythrocytes
Cyanate increases the affinity of 02 to HbS and lowers the
formation of deoxy HbS. However, it causes certain side effects
like peripheral nerve damage.
In patients with severe anemia, repeated blood transfusion is required.
This may result in iron overload and cirrhosis of liver.

— Replacement of HbS with other forms of hemoglobins has been

tried.
— Fetal hemoglobin (HbF) reduces sickling. Sickle-cell disease
awaits gene-replacement therapy
 Homocystinuria
— The homocystinurias are a group of disorders
involving defects in the metabolism of homocysteine
— The diseases are inherited as autosomal recessive
illnesses, characterized by high plasma and urinary
levels of homocysteine and methionine and low
levels of cysteine
— The most common cause of homocystinuria is a
defect in the enzyme cystathionine β-synthase
— This enzyme is involved in conversion of
homocysteine to cystathionine
 Homocystinuria
— Individuals who are homozygous for cystathionine β-
synthase deficiency exhibit:
i. Ectopia lentis (displacement of the lens of the eye)
ii. Skeletal abnormalities
iii. Premature arterial disease
iv. Osteoporosis
v. Mental retardation
— Patients can be responsive or nonresponsive to oral
administration of pyridoxine (vitamin B6)—a
coenzyme of cystathionine β-synthase
 Homocystinuria
— Vitamin B6–responsive patients usually have a milder
and later onset of clinical symptoms compared with
B6-nonresponsive patients
— Treatment includes:
i. Restriction of methionine intake
ii. Supplementation with vitamins B6, B12, and folate
 Alkaptonuria
— Alkaptonuria is a rare metabolic disease involving a
deficiency in homogentisic acid oxidase
— This deficiency results in the accumulation of
homogentisic acid
— This reaction occurs in the normal degradative pathway of
tyrosine
— The illness has three characteristic symptoms:
i. Homogentisic aciduria (the patient's urine contains
elevated levels of homogentisic acid, which is oxidized
to a dark pigment on standing)
ii. Large joint arthritis
iii. Black ochronotic pigmentation of cartilage and
collagenous tissue
Alkaptonuria
 Alkaptonuria
— Patients with alkaptonuria are usually asymptomatic
until about the age of 40
— Dark staining of the diapers sometimes can indicate
the disease in infants, but usually no symptoms are
present until later in life
— Diets low in protein—especially in phenylalanine and
tyrosine—help reduce the levels of homogentisic acid,
and decrease the amount of pigment deposited in
body tissues
— Although alkaptonuria is not life-threatening, the
associated arthritis may be severely crippling
Hemoglobin Catabolism
— When red cells reach the end of their life due to aging
or defects, they are broken down, the hemoglobin
molecule is broken up and the iron gets recycled.
— When the porphyrin ring is broken up, the fragments
are normally secreted in the bile by the liver.
— This process also produces one molecule of carbon
monoxide for every molecule of heme degraded.
— The other major final product of heme degradation is
bilirubin.
Hemoglobin Catabolism
— Increased levels of this chemical are detected in the
blood if red cells are being destroyed more rapidly
than usual.
— Improperly degraded hemoglobin protein or
hemoglobin that has been released from the blood
cells too rapidly can clog small blood vessels,
especially the delicate blood filtering vessels of the
kidneys, causing kidney damage.
Heme Catabolism
— The first step in the
degradation of heme is
catalyzed by the
microsomal heme
oxygenase system of
the reticuloendothelial
cells.
— In the presence of
NADPH and O2, the
enzyme converts heme
to Biliverdin.
Biliverdin
— Biliverdin is a green tetrapyrrolic bile pigment, and is
a product of heme catabolism.
— It is the pigment responsible for a greenish color
sometimes seen in bruises.
— Biliverdin has been found in excess in the blood of
humans suffering from hepatic diseases.
— Jaundice is caused by the accumulation of biliverdin
or bilirubin (or both) in the circulatory system and
tissues.
Heme Catabolism
— Biliverdin is reduced, forming the red-orange bilirubin.
— Bilirubin and its derivatives are collectively termed bile
pigments.
— Bilirubin is only slightly soluble in plasma and,
therefore, is transported to the liver by binding non-
covalently to albumin.
Heme Catabolism
— Certain anionic drugs, such as salicylates and
sulfonamides, can displace bilirubin from albumin,
permitting bilirubin to enter the central nervous
system. This causes the potential for neural damage
in infants.
— Bilirubin dissociates from the carrier albumin
molecule and enters a hepatocyte, where it binds to
intracellular proteins, particularly the protein ligandin.
Unconjugated (indirect) Bilirubin
— Erythrocytes generated in the bone marrow are
disposed of in the spleen when they get old or
damaged.
— This releases hemoglobin, which is broken down to
heme as the globin parts are turned into amino acids.
— The heme is then turned into unconjugated bilirubin
in the reticuloendothelial cells of the spleen.
— This unconjugated bilirubin is not soluble in water. It is
then bound to albumin and sent to the liver.
Formation of bilirubin
diglucuronide
— In the hepatocyte, the solubility of bilirubin is
increased by the addition of two molecules of
glucuronic acid.
— This process is referred to as conjugation.
— The reaction is catalyzed by microsomal bilirubin
glucuronyltransferase using uridine diphosphate-
glucuronic acid as the glucuronate donor.
— Varying degrees of deficiency of this enzyme result
in Crigler-Najjar I and II and Gilbert syndrome, with
Crigler-Najjar I being the most severe deficiency.
Secretion of bilirubin into bile
— Bilirubin diglucuronide (conjugated bilirubin) is
actively transported against a concentration gradient
into the bile canaliculi and then into the bile.
— This energy-dependent, rate-limiting step is
susceptible to impairment in liver disease.
— A deficiency in the protein required for transport of
conjugated bilirubin out of the liver results in Dubin-
Johnson syndrome.
— Unconjugated bilirubin is normally not secreted.
Conjugated (direct)

— Much of it goes into the bile and thus out into the
small intestine.
— Some of the conjugated bilirubin remains in the large
intestine and is metabolised by colonic bacteria to
urobilinogen, which is further metabolized to
stercobilinogen, and finally oxidised to stercobilin.
— This stercobilin gives feces its brown color.
— Some of the urobilinogen is reabsorbed and excreted
in the urine along with an oxidized form, urobilin.
JAUNDICE
Jaundice
— Jaundice (also called icterus) refers to the yellow color
of skin, nail beds, and sclerae (whites of the eyes)
caused by deposition of bilirubin, secondary to
increased bilirubin levels in the blood (hyper-
bilirubinemia, .
— Although not a disease, jaundice is usually a
symptom of an underlying disorder
— Jaundice can be classified into three major forms.
Hemolytic jaundice
— The liver has the capacity to conjugate and excrete
over 3,000 mg of bilirubin per day, whereas the
normal production of bilirubin is only 300 mg/day.
— This excess capacity allows the liver to respond to
increased heme degradation with a corresponding
increase in conjugation and secretion of bilirubin
diglucuronide.
Hemolytic jaundice
— However, massive lysis of red blood cells (for
example, in patients with sickle cell anemia, pyruvate
kinase or glucose 6-phosphate dehydrogenase
deficiency) may produce bilirubin faster than it can be
conjugated.
— More bilirubin is excreted into the bile, the amount of
urobilinogen entering the enterohepatic circulation is
increased, and urinary urobilinogen is increased.
— Unconjugated bilirubin levels become elevated in the
blood, causing jaundice.
Hepatocellular jaundice
— Damage to liver cells (for example, in patients with
cirrhosis or hepatitis) can cause unconjugated
bilirubin levels to increase in the blood as a result of
decreased conjugation.
— The bilirubin that is conjugated is not efficiently
secreted into the bile, but instead diffuses (“leaks”)
into the blood.
Hepatocellular jaundice
— Urobilinogen is increased in the urine because
hepatic damage decreases the enterohepatic
circulation of this compound, allowing more to enter
the blood, from which it is filtered into the urine.
— The urine thus becomes dark, whereas stools are a
pale, clay color.
— Plasma levels of AST (SGOT) are elevated, and the
patient experiences nausea and anorexia.
Obstructive jaundice
— In this instance, jaundice is not caused by
overproduction of bilirubin or decreased conjugation,
but instead results from obstruction of the bile duct.
— For example, the presence of a hepatic tumor or bile
stones may block the bile ducts, preventing passage of
bilirubin into the intestine.
— Patients with obstructive jaundice experience
gastrointestinal pain and nausea, and produce stools
that are a pale, clay color, and urine that darkens upon
standing.
Jaundice in newborns
— Newborn infants, particularly if premature, often
accumulate bilirubin, because the activity of hepatic
bilirubin glucuronyltransferase is low at birth—it reaches
adult levels in about four weeks .
— Elevated bilirubin, in excess of the binding capacity of
albumin, can diffuse into the basal ganglia and cause toxic
encephalopathy (kernicterus).
— Thus, newborns with significantly elevated bilirubin levels
are treated with blue fluorescent light , which converts
bilirubin to more polar and, hence, water-soluble isomers.
— These photoisomers can be excreted into the bile without
conjugation to glucuronic acid.