LYSOSOSMAL STORAGE DISEASES – LECTURE NOTES

The Lysosome
Lysosomes are membrane-enclosed organelles, characterised by internal acid pH,
and are responsible for degrading and recycling cellular and extracellular material.
Lysosomes have different functions within the cells.
 Lysosomes are involved in the endocytic process, though which the cell
internalises external material via formation of vesicles. Similarly, lysosomes
are involved in autophagy when the cell degrades cytosolic proteins and
senescent organelles.
 In lysosomal storage disorders, the endocytic and autophagy pathways are
disrupted.
 Lysosomes are also involved in apoptosis, as result of cellular stress.
 When a protein is not folded correctly and the lysosomal system doesn’t
work properly, proteins accumulate in the cytosol, activate the unfolded
protein response leading to apoptosis.
 Lysosomes are responsible for the degradation of dysfunctional
mitochondria. In lysosomal storage disorders damaged mitochondria are not
clear from the cytosol.
All these cellular functions are tightly connected, leading to a pathological cascade
that ends with cell death.

Lysosomal Storage Diseases

Lysosomal Storage Disorders are rare genetic diseases in which mutations in
lysosomal proteins cause accumulation of biological material, leading to reduced life
span in the patients. Pioneering biochemical studies between the early 1970s and
1990s attributed the pathogenesis of LSDs to a disrupted catabolic function of
lysosomal enzymes and consequent primary lysosomal substrate storage.
However, in the past two decades, research expanded this classical view to a more
complex scenario, whereby multiple primary defects produced by lysosomal enzyme
deficiency concur, leading to a range of cellular abnormalities, including oxidative
stress, mitochondrial alterations, cell signalling defects, and calcium dyshomeostasis.
LSD are rare but have a high combined frequency in the population. Some ethnic
groups have higher carrier frequency.

The type of mutation can influence the severity and onset of the disease, with
complete loss of activity correlating to more severe phenotypes. However here is not
always a direct correlation between genotype and phenotype, so it’s difficult to
predict the progression of the disease in each patient.

Lysosomal storage disorders are classified by the substrate that accumulates, by the
physiological function that is affected, or by genetic profile. However the same
pathway can be affected in different diseases, leading to the accumulation of the
same downstream material. Lysosomes are ubiquitous: if one enzyme is deficient the
whole digestive machinery is arrested or disrupted.
  Primary storage = lysosomal buildup of biochemical components that
accumulate as a direct result of a failure in degradation mechanisms.
 Secondary storage = material accumulating from subsequent downstream
compromise in lysosomal or lysosomal-related functions.
The buildup of primary storage material further compromises the degradative
capacity of the lysosome, increasing accumulation of secondary storage material and
thus creating a deleterious cycle. Both primary and secondary storage effects
downstream events, like lysosomal pH regulation, coordination of fusion events with
phagosomes and endosomes or signal transduction.

Lysosomal storage disorders are characterised by a complex pathobiology.

Accumulation of biological material causes disrupted protein trafficking, expansion
of the lysosomal system, increased autophagy and apoptosis, leading to
inflammation and macrophages activation. Because the lysosomal system is tightly
connected to other cellular pathways, lysosome storage disorders can be linked to
more common diseases like Parkinson or Alzheimer.

The glycosphingolipid pathway is the most affected metabolic pathway in lysosomal

storage disorders. This pathway can be disrupted at different levels, resulting in
accumulation of different substrates. Complete disruption of the glycosphingolipid
pathways is incompatible with life. Accumulation of specific macromolecules
activates different pathological responses, all leading to cytotoxicity and apoptosis.

Clinical features
Because all cells in the body are affected, lysosomal storage diseases are multi-
systemic. Common clinical features are enlargement of spleen and liver, heart and
lung failure, anaemia, bone crisis and skin lesions.
The most acute forms are characterised by central and peripheral nervous system
pathology, which usually leads to premature death. Patients can develop
neurocognitive retardation, movement disorders, seizures and optical
manifestations. The typical developmental pattern is regressive, with loss of more
recently acquired skills. Many children are normal until age of 1, then fail to develop
normal speech and lose motor-coordination skills. By mid-teenage years most of
affected patients are dependent on their carers. Neuropathology con be restricted to
a specific cell population in the brain, or widespread to the whole CNS. However the
pathological mechanisms underlying neuropathology are complex and not fully
understood.

In particular neuroinflammation plays an important role on neuronal survival.

Chronic neuroinflammation can have detrimental effects on neural cells. Persistent
inflammation can elicit additional damage, further perpetuating the inflammatory
cycle and making neurons more vulnerable to toxic effects.

It is still not clear whether neurodegeneration triggers inflammation or

neuroinflammation is the cause for neuronal death. A wide range of
glycosphingolipids storage disorders present with neuroinflammation and immune
dysregulation. Patients show alterations in the immune system: microgliosis along
with neuronal loss and astrogliosis, increased serum levels of cytokines and activated
T lymphocytes in the peripheral blood. Human and experimental data support that
glycosphingolipid contribute to immune-mediated mechanisms contributing to the
establishment of chronic neuroinflammation.

Glycosphingolipid metabolism in Parkinson’s disease

• The relationship between glycosphingolipids and Parkinson’s disease has
gained attention since carrying a mutated allele of the GBA gene encoding
the lysosomal glucocerebrosidase was identified as one of the most
frequent genetic risk factor for Parkinson’s disease.
• Alterations in the biosynthesis or catabolism of glucosylceramides or
downstream glycosphingolipids occur in the brain of patients with
Parkinson’s disease.
• A link between glycosphingolipids in Parkinson’ s disease is also supported
by the association to Parkinson’s disease of other genes related to
glycosphingolipid storage disorders: ie lysosomal integral membrane
protein type-2 (LIMP2) that is involved in the delivery of
glucocerebrosidase to lysosomes; Cathepsin D involved in the
posttranslational cleavage of prosaposin thus leading to the production of
the glucocerebrosidase activator saposin C.
• GSLs-related genetic determinants of Parkinson’s disease and central and
peripheral metabolic changes in patients strongly suggest that
glycosphingolipids contribute to Parkinson’s disease pathogenesis.
• Parkinson’s disease may share some disease-related molecular pathways
with lysosomal glycosphingolipid storage disorders that also frequently
present with neuroinflammation and neurodegeneration.

Gaucher Disease
Gaucher disease (GD), resulting from deficient lysosomal glucocerebrosidase, is
caused by bi-allelic variants in GBA1 and is the most common genetic risk factor for
the more common neurodegenerative disorder, Parkinson disease. Deficiencies in
this lysosomal enzyme disrupt the conversion of glucosylceramide into glucose and
ceramide, resulting in the accumulation of glucosylceramide, as well as its
deacylated form glucosylsphingosine, in lysosomes. There are both neuronopathic
and non-neuronopathic forms of GD, although the basis for the neuropathology seen
is not fully understood.
Manifestations may result from oxidative stress and inflammatory responses due to
complex interconnection of downstream factors such as substrate accumulation,
endoplasmic reticulum (ER) stress, unfolded protein response (UPR), calcium
dysregulation, mitochondrial dysfunction, defective autophagy, accumulation of α-
synuclein aggregates, altered secretion and function of extracellular vesicles (EVs),
and immunologic hyperactivity. The primary input source is a
causative GBA1 mutation that results in activation of multiple sub-cellular
pathophysiologic processes. Misfolded GCase in ER can trigger the unfolded protein
response (UPR) as an adaptive mechanism to the generated ER stress. Prolonged
activation of UPR produce high levels of reactive oxygen species (ROS) leading to
oxidative stress. Loss of GCase activity also leads to mitochondrial dysfunction, GL-
1/Lyso GL-1 accumulation in lysosomes and potential alterations in the release and
function of exosomes, all of which can contribute to further oxidative stress and
downstream inflammation. Eventually, it leads to cellular dysfunction or apoptosis
that are expressed as various clinical complications in patients.

Patients with visceral pathology can usually live until adulthood, while type 2
patients die within 2-4 years of age.

Niemann-Pick
Niemann–Pick type C (NPC) disease is caused by bi-allelic variants in two genes,
NPC1 and NPC2. Loss of NPC1 causes abnormal intra-lysosomal accumulation of
unesterified cholesterol and sphingolipids in the brain, liver, and spleen.
Niemann-Pick disease presents with both visceral and neurological symptoms. The
onset and progression can vary. While the age at presentation and the initial
manifestations are variable, progressive dementia and neurological signs are almost
universal among patients with NPC.

Batten Disease
Batten disease is the collective name for over 10 different disorders, characterised by
mutations in the CLN genes. Although each disease has different onset, they are all
characterised by loss of vision and severe neuropathology. Collectively NCLs are
considered the most common inherited neurodegenerative disorder of childhood,
but accurate incidence and prevalence rates are difficult to obtain.
Typically disease progression is more rapid for individuals presenting symptoms early
in life. 10-12 cases are diagnosed in the UK every year. Of these ½ of patients have
CLN2, ¼ CLN3 ant the rest present with the rarer forms. In addition to genetic and
allelic heterogeneity, there is clinical variability between and within families. The
understanding of the neuropathological mechanisms is incomplete, as there is no
direct relationship between storage material and cell death.

Other LSDs
Fabry Disease
• X-linked disorder caused by deficiency in a-galactosidase A.
• Incidence 1:40,000
• Progressive, multisystem disorder with various age of onset.
• Cardiovascular disease is the most common cause of death.
• Licenced ERT products.
Gangliosidoses
• Heterogeneous group resulting from deficiency of lysosomal enzyme b-
galactosidase.
• All diseases have a neurological component, caused by accumulation of high
molecular weight gangliosidoses in the neurons.
• The most common variant of GM2-gangliosidosis is late-infantile Tay-Sachs,
with rapid neurological deterioration, blindness, and seizures.
• Sandhoff disease is almost indistinguishable, with liver enlargement and
severe neurological deterioration.
Metachromatic and Globoid Cell Leukodystrophies
• MLD and Krabbe disease are autosomal recessive diseases caused by
deficiency of arysulfatase A and galactosylceramidase.
• The pathological hallmark is loss of oligodendrocytes leading to progressive
neurodegeneration.
Mucopolysaccharidoses
• Group of 11 disorders characterised by deficiency in enzymes involved in the
degradation pathway of GAGs.

Diagnosis and Treatments

Because lysosomal storage disorders are rare diseases, there is no routine pre-natal
screening. Diagnosis is often delayed and can be difficult for the lack of reliable
biomarkers.
Some newborn screening programs exist but are not available in the clinics.
Particularly for treating the neuropathology, early diagnosis is very important. Not
all neonates present symptoms, so it is difficult to diagnose patients at birth. In
some cases, the accumulation of material starts already during gestations, and
babies develop symptoms before birth. However it remains difficult to establish a
correct diagnosis on the sole basis of the phenotypic manifestations.

Therapies can act at different levels, from palliative management of symptoms to

gene therapy. Because lysosomal storage disorders are rare diseases, usually
treatments are very expensive. The overall impact of LSDs on patients, family and
the community is not always well documented. Moving to new more effective
therapies calls for early detection through newborn and population screening
programs. As each LSD has a broad clinical heterogeneity, gathering epidemiological
data is problematic. The economic pressure on the health system encourages
cheaper treatments, like chaperone therapies. At the same time there a push to
develop and use expensive treatments like gene therapy for patients who have
established disease. Genetic counselling should predict the likely phenotype and
clinical progression, possible CNS involvement, planning options to high-risk family
members and therapeutic strategies.

 Patients can undergo organ transplantation or hematopoietic stem cell

transplant. This works for soluble enzymes only, is associated to high risk of
complications and doesn't seem to have an effect on the CNS pathology.
 Substrate reduction therapy aims to reduce the synthesis the accumulating
macromolecule upstream the mutated enzyme. There a couple of SRT
products for Gaucher disease, that block the synthesis of glucosylceramide.
Miglustat can cross the blood brain barrier but is associated to
gastrointestinal side effects, while eliglustat does not have affect in the CNS.
 Enzyme replacement therapy is the gold standard for many LSDs. It consists
in repeated infusions of recombinant enzyme, which clears the accumulated
substrate. However the enzyme does not cross the blood brain barrier, so
ERT is not suitable for the neurological symptoms.
 Pharmacological chaperones are molecules that bind to the protein and
promote its correct folding. These molecules are effective in those cases
where the mutation does not affect the catalytic site of the enzyme and the
protein retains some residual activity.
 Lysosomal storage disorders are the ideal candidate for gene therapy, where
the mutated gene is replaced with a functional copy. Different gene therapy
vectors exist, although vector based on viruses are so far the most effective in
delivery gene to the organism. Many gene therapy clinical trials are currently
ongoing, however this is a very expensive treatment option.
Approved Therapies (2018)
Summary
Lysosomal storage disorders are rare genetic diseases of metabolism. They are
caused by mutations in lysosomal enzymes and proteins, leading to accumulation of
biological materials.
Because the lysosomal system is tightly connected with other cellular compartment,
many cellular functions are affected.
LSDs presents with both systemic and neurological symptoms and different
mutations influence the onset and progression of the disease.
There are several treatment options available, but not all are feasible for treating the
neurodegeneration.